Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
75 Cards in this Set
- Front
- Back
|
What is the first component for decision making in the critical thinking model? |
Scientific Knowledge base |
|
|
Completing a comprehensive database is done during which phase of the nursing process? |
Assessment |
|
|
After data collection and analysis to identify patient problems, what is the next phase of the nursing process? |
Evaluation |
|
|
Read the following nursing diagnosis. Which part(s) identifies the defining characteristic(s)? Impaired gas exchange r/t lack of oxygen aeb pt exhibiting shortness of breath & nasal cannula out of pt's nose. |
Pt exhibiting shortness of breath & nasal cannula out of pt's nose. |
|
|
Give an appropriate goal for this nursing diagnosis: Acute pain r/t surgical site infection aeb pt rates pain 9/10 continuously. |
(could be a number of responses but goals should be written/stated as:) Pt will ..... by.... (example: Pt will rate pain 4/10 on the pain scale by 1400) |
|
|
During which phase of the nursing process are nursing interventions carried out? |
Implementation |
|
|
Assessing whether or not a pt met his/her goal takes place in which phase of the nursing process? |
Evaluation |
|
|
If the pt's goal is not met what should the nurse do? |
Re-assess the patient and identify the problem that prevented the pt from meeting their goal |
|
|
When a nurse is consulting a physician or other healthcare personnel what should be done first? |
Problem identification |
|
|
this involves considering all aspects of a situation when making decisions and considering what is important in any given situation. |
Critical thinking. |
|
|
What is the most preferred way to take a temperature? |
Oral |
|
|
What aspect of developing critical thinking involves using past experiences to help in the future? |
Reflective Journaling |
|
|
What is considered a normal blood pressure in an adult? |
<120/<80 |
|
|
If a pt's goal was not met what needs to be done first? |
Re-assess the pt |
|
|
Nurses need to adhere to hospital policies when providing pt care. What is the term for these policies? |
Institutional practice guidelines. |
|
|
What is the most important thing to do to stop the spread of infection? |
Hand washing |
|
|
Name at least 2 signs and symptoms of localized inflammatory response. |
Edema, redness, pain, swelling, loss of function |
|
|
Besides during surgery when is sterile technique used? |
Catheter insertion, most dressing changes, NT/Trach suctioning. |
|
|
Which organism is hand sanitizer ineffective against? |
C-diff |
|
|
When coming in contact with bodily fluids it is important to implement............. precautions |
standard |
|
|
How should a temperature be obtained on a confused adult? |
Axillary or tympanic |
|
|
where is an infant's pulse taken? Where is an adults pulse takes? |
1. Brachial 2. radial |
|
|
What does dysrhythmia mean? |
Abnormal beat. |
|
|
What are some factors that would affect a patients pulse? (name 3) |
1. Drugs 2. emotions 3. physical activity |
|
|
What are signs and symptoms of dyspnea? (name 3) |
1. Accessory muscle use 2. Decrease in oxygen saturation 3. Nasal flaring |
|
|
What is critical thinking? |
a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant
|
|
|
What does each step mean in the critical thinking model? |
There are 3 levels: 1. Basic : The learner trusts that the expert has all the right answers to the problem. 2. Complex : begin to separate themselves from the experts. 3. Commitment: when a person makes their own decisions and accepts accountability for the decisions made. |
|
|
What is the nursing process? |
a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
|
|
|
What is ADPIE? |
1. Assess: gather information about the patient 2. Diagnose: Identify the patients problem 3. Plan: Set goals and desired outcomes and identify appropriate nursing actions 4. Implement: perform nursing actions as identified in planning 5. Evaluate: Determine if goal and expected outcomes are achieved. |
|
|
Data collection |
You learn to differentiate important data from the total data collected. A cue is information that you obtain through use of the senses. An inference is your judgment or interpretation of these cues.
|
|
|
What are the types of data?
|
1. subjective data- is the pt's description 2. Objective data- measurable information. i.e. Blood pressure, temp, pulse. |
|
|
Sources of data
|
2. Family and/or significant others 3. The healthcare team 4. Medical records 5. Other records (school, etc) and scientific data |
|
|
What are the 7 guidelines for writing goals? |
1. Patient centered 2. Singular goal/ outcome 3. observable 4. measurable 5. time- limited 6. mutual factors 7. realistic |
|
|
Discontinuing a plan of care
|
After you determine that expected outcomes and goals have been met, confirm this evaluation with the patient when possible. If you and the patient agree, you discontinue that portion of the care plan. |
|
|
What is delegation?
|
Process of assigning another member of the health care team to be responsible for aspects of patient care (e.g., assigning nurse assistants to bathe a patient). |
|
|
What is interpretation?
|
|
|
|
proper hand hygiene
|
includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub. Handwashing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds. |
|
|
Equipment use and hygiene
|
All equipment that is being reused should be cleaned before being used again
|
|
|
What are the 4 stages of infectious process?
|
1. Incubation stage-
Interval between entrance of pathogen into body and appearance of first symptoms 2. Prodromal stage- Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms 3. Illness stage- Interval when patient manifests signs and symptoms specific to type of infection. 4.Convalescence- Interval when acute symptoms of infection disappear. |
|
|
What are the 6 links in the chain of infection? |
1. An infectious agent or pathogen 2. A reservoir or source for pathogen growth 3. A port of exit from the reservoir 4. A mode of transmission 5. A port of entry to a host 6.A susceptible host |
|
|
What happens if the chain of infection stays unbroken? What happens if it breaks? |
1. If the chain infection stays unbroken an infection occurs. 2. When the chain is broken this prevents infection. |
|
|
S/S of localized inflammatory response
|
the patient usually experiences localized symptoms such as pain, tenderness, and redness at the wound site. |
|
|
S/S of systemic inflammatory response
|
An infection that affects the entire body instead of just a single organ or part |
|
|
What is HAI?
|
Hospital Acquired Infection |
|
|
What causes HAI? |
They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities. |
|
|
Steps in putting on PPE
|
a. Apply cover gown, being sure that it covers all outer garments. Pull sleeves down to wrist. Tie securely at neck and waist. b. Apply either surgical mask or respirator around mouth and nose c. If needed, apply eyewear or goggles snugly around face and eyes. If prescription glasses are worn, side shield may be used. d. Apply clean gloves |
|
|
When is sterile technique broken? |
Sterile touching clean becomes contaminated. Sterile touching contaminated becomes contaminated. Sterile field becomes wet. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. A sterile object or field becomes contaminated by prolonged exposure to air. |
|
|
Medical VS. Surgical asepsis |
Surgical Asepsis: sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area |
|
|
What is PPE? |
It is the protective equipment you wear to prevent the spread of infection. I.E. gowns, eye wear, face masks, gloves.
|
|
|
When do we wear PPE?
|
When a patient is on isolation, for sterile procedures and also if you are coming into contact with bodily fluids. |
|
|
What are types of isolation?
|
Contact precautions: must wear gloves Droplet precautions: Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. Airborne precautions: Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. This requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. All health care personnel wear an N95 respirator every time they enter the room. |
|
|
C-diff
|
Is a spore that is contagious that is not killed by sanitizer. S/S include runny diarrhea, with a distinct odor as well as abdominal cramping.
|
|
|
What is to be done if a healthcare provider is stuck by a needle or cut by a scapel |
Report it immediately |
|
|
What affects temperature?
|
Age Exercise Hormonal Level Circadian Rhythm Environment Temperature alterations |
|
|
What is temperature regulation? |
Thermoregulation (balance between loss of heat and production of heat) |
|
|
What are the routes to assess temp? |
Oral tympanic rectal axilla skin temporal |
|
|
what is the normal temperature range? |
96.8° F to 100.4° F or 36° C to 38° C |
|
|
What do you do if a temperature is abnormal? |
Give patient fever reducer Ice packs Recheck |
|
|
Acceptable ranges of heart rate for each age group
|
Infant- 120-160 toddler- 90-140 Preschooler- 80-110 School-aged child- 75-100 adolescents- 60-90 Adult-60-100 |
|
|
What are factors that will affect pulse?
|
•Exercise •Temperature •Emotions •Drugs •Hemorrhage •Position changes •Lung conditions |
|
|
Where are the pulse points?
|
–temporal –carotid –apical –brachia –radial –ulnar –femoral –popliteal –posterior tibia –dorsalis pedis |
|
|
Bradycardia VS. Tachycardia
|
Tachycardia- Fast heart beat |
|
|
What is a pulse deficit?
|
The difference between the apical pulse and radial pulse
|
|
|
What is the normal range in BP for adults?
|
<120/<80
|
|
|
Pre-hypertensive Vs. hypertensive
|
Stage 1 hypertension- 140-159/90-99 Stage 2 hypertension- >160/ <100
|
|
|
What factors affect Blood pressure?
|
•Age •Stress •Ethnicity •Gender •Pain •Daily variation •Medications •Activity, weight •Smoking •Diabetes |
|
|
What is pulse pressure?
|
The numeric difference between your systolic and diastolic blood pressure
|
|
|
What are normal ranges for respirations?
|
Newborn- 30-60 Infant-30-50 Toddler-25-32 Child- 20-30 Adolescent- 16-19 Adult- 12-20 |
|
|
What factors affect Respiration rates? |
Exercise Anxiety Neurological injury body position Acute pain Smoking Medications Hemoglobin function |
|
|
What are the different types of respirations?
|
•Hyperventilation •Hypoventilation •Cheyne-Stokes respiration •Kussmaul’s respiration •Biot’s respiration •Bradypnea •Tachypnea •Hyperpnea •Apnea |
|
|
What do you do if pulse oxidation is abnormal? |
Call physician |
|
|
What is pulse ox and how do you assess it?
|
Pulse ox is a machine that measure that amount of hemoglobin you have. You usually take it on a patients finger.
|
|
|
What is hypoxia and where do we check for it?
|
deficiency in the amount of oxygen reaching the tissues and we check the pulse ox.
|
|
|
On what patient do we check the mucous membranes for hypoxia?
|
African American patients
|
|
|
When do we check the nail bed? |
On patients with severe emphysema |
