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249 Cards in this Set

  • Front
  • Back

A cue is
information that you obtain through use of the senses.
An inference is
your judgment or interpretation of cues
Subjective data are
your clients' verbal descriptions of their health problems. Only clients provide subjective data.
Objective data are
observations or measurements of a client's health status. Inspection of the condition of a wound, a description of an observed behavior, and the measurement of blood pressure are examples of objective data. The measurement of objective data is based on an accepted standard,
The nursing health history includes
data about the client's current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness
Define back channeling.
Responses that include active listening prompts such as “all right,” “go on,” or “uh-huh,” indicating that you have heard what the client says and are attentive to hear the full story.
What is The review of systems (ROS) is a systematic method for collecting data on all body systems?
(ROS) is a systematic method for collecting data on all body systems
What is Data analysis?
"Recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the client's responses to a health problem.
A medical diagnosis is:
the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures.
A nursing diagnosis is:
a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat
A collaborative problem is:
an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status - when nurses intervene in collaboration with personnel from other health care disciplines
When was the concept of nursing diagnosis first proposed?
1950
For what purpose was the NANDA formed?
“to develop, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses”
What purpose does standard formal nursing diagnostic statements fill?
"Provides precise definition, giving health care team a common language for understanding client's needs -- Allows nurses to communicate among themselves and beyond --
Define Clinical criteria.
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion.
Define “risk nursing diagnosis.”
a description human responses to health conditions/life processes that will possibly develop
Define health promotion nursing diagnosis.
is a clinical judgment of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors
Define wellness nursing diagnosis.
a description of human responses to levels of wellness in an individual, family, or community that have a readiness for
Define diagnostic label.
the name of the nursing diagnosis as approved by NANDA
Define “related factor.” (R/T)
a condition or etiology identified from the client's assessment data.
At what stages might nursing diagnosis care encounter error?
data collection, clustering, interpretation, and statement of the diagnosis
After determining a nursing diagnosis of acute pain, the nurse develops the following appropriate client-centered goal: A. Encourage client to implement guided imagery when pain begins. B. Determine effect of pain intensity on client function. C. Administer analgesic 30 minutes before physical therapy treatment. D. Pain intensity reported as a 3 or less during hospital stay.
D. Pain intensity reported as a 3 or less during hospital stay.
When developing a nursing care plan for a client with a fractured right tibia, the nurse includes in the plan of care independent nursing interventions, including: A. Apply a cold pack to the tibia. B. Elevate the leg 5 inches above the heart. C. Perform range of motion to right leg every 4 hours. D. Administer aspirin 325 mg every 4 hours as needed
B. Elevate the leg 5 inches above the heart.
Which of the following nursing interventions are written correctly? (Select all that apply.) A. Apply continuous passive motion machine during day. B. Perform neurovascular checks. C. Elevate head of bed 30 degrees before meals. D. Change dressing once a shift.
C. Elevate head of bed 30 degrees before meals.
A client’s wound is not healing and appears to be worsening with the current treatment. The nurse first considers: A. Notifying the physician B. Calling the wound care nurse C. Changing the wound care treatment D. Consulting with another nurse
B. Calling the wound care nurse
When calling the nurse consultant about a difficult client-centered problem, the primary nurse is sure to report the following: A. Length of time current treatment has been in place. B. The spouse’s reaction to the client’s dressing change C. Client’s concern about the current treatment D. Physician’s reluctance to change the current treatment plan
A. Length of time current treatment has been in place.
The primary nurse asked a clinical nurse specialist (CNS) to consult on a difficult nursing problem. The primary nurse is obligated to: A. Implement the specialist’s recommendations B. Report the recommendations to the primary physician C. Clarify the suggestions with the client and family members D. Discuss and review advised strategies with CNS
D. Discuss and review advised strategies with CNS
Nursing interventions for a specific problem developed in the hospital setting do not require a _______________, but this aspect is important for the nursing student in order to reinforce the importance of evidence-based nursing practice.
RATIONALE
After assessing the client, the nurse formulates the following diagnoses. Place them in order of priority, with the most important (classified as high) listed first. 1. Constipation 2. Anticipatory grieving 3. Ineffective airway clearance 4. Ineffective tissue perfusion
3. Ineffective airway clearance 4. Ineffective tissue perfusion 1. Constipation 2. Anticipatory grieving
During the planning phase of the nursing process, the nurse along with the client decides the following (select all that apply): A. Nursing diagnosis B. Client-centered goals C. Nurse-centered priorities D. Interventions E. Expected outcomes
b, e. These are the main components of the planning phase of the nursing process., a. The nurse determines these from the assessment. c. The client should be the focus of the planning stage. d. Interventions are initially determined by the nurse.
A client with a spinal cord injury was admitted today to a rehabilitation institution. The rehabilitation nurse develops long-term goals that focus on four aspects of care. Those four aspects are:
1. Prevention (of complications) 2. Rehabilitation (return to maximum function) 3. Discharge (returning to the community) 4. Health education (knowledge regarding maintaining wellness based on age and gender)
ONCE A NURSE ASSESSES A CLIENT’S CONDITION AND IDENTIFIES APPROPRIATE NURSING DIAGNOSES A: A. PLAN IS DEVELOPED FOR NURSING CARE B. PHYSICAL ASSESSMENT BEGINS C. LIST OF PRIORITIES IS DETERMINED D. REVIEW OF THE ASSESSMENT IS CONDUCTED WITH OTHER TEAM MEMBER
A. PLAN OS DEVELOPED FOR NURSING CARE
PLANNING IS A CATEGORY OF NURSING BEHAVIORS IN WHICH - A. THE NURSE DETERMINES THE HEALTH CARE NEEDED FOR THE CLIENT B. THE PHYSICIAN DETERMINES THE PLAN OF CARE FOR THE CLIENT C. CLIENT-CENTERED GOALS AND EXPECTED OUTCOMES ARE ESTABLISHED D. THE CLIENT DETERMINES THE CARE NEEDED
C. CLIENT-CENTERED GOALS AND OUTCOMES ARE ESTABLISHED
PRIORITIES ARE ESTABLISHED TO HELP THE NURSE ANTICIPATE AND SEQUENCE NURSING INTERVENTIONS WHEN A CLIENT HAS MULTIPLE PROBLEMS OR ALTERATIONS. PRIORITIES ARE DETERMINED BY THE CLIENT’S: A. PHYSICIAN B. NON-EMERGENT NON LIFE THREATENING NEEDS C. FUTURE WELL BEING D. URGENCY OF PROBLEMS
D. URGENCY OF PROBLEMS
A CLIENT CENTERED GOAL IS A SPECIFIC AND MEASURABLE BEHAVIOR OR RESPONSE THAT REFLECTS A CLIENTS - A. DESIRE FOR SPECIFIED HEALTH CARE INTERVENTIONS B. HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION C. PHYSICIANS GOAL FOR THE SPECIFIC CLIENT D. RESPONSE WHEN COMPARED TO ANOTHER CLIENT WITH A LIKE PROBLEM
B. HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION
FOR CLIENTS TO PARTICIPATE IN GOAL SETTING THEY SHOULD BE - A. ALERT AND HAVE SOME DEGREE OF INDEPENDENCE B. AMBULATORY AND MOBILE C. ABLE TO SPEAK AND WRITE D. ABLE TO READ AND WRITE
A. ALERT AND HAVE SOME DEGREE OF INDEPENDENCE
THE NURSE WRITES AN EXPECTED OUTCOME STATEMENT IN MEASURABLE TERMS. AN EXAMPLE IS: - A. CLIENT WILL HAVE LESS PAIN B. CLIENT WILL BE PAIN FREE C. CLIENT WILL REPORT PAIN ACTIVITY LESS THAN 4 ON A SCALE OF 0-10 D. CLIENT WILL TAKE PAIN MEDICATION EVERY 4 HOURS
C. CLIENT WILL REPORT PAIN ACTIVITY LESS THAN 4 ON A SCALE OF 0-10
AS GOALS OUTCOMES AND INTERVENTIONS ARE DEVELOPED THE NURSE MUST: A. BE IN CHARGE AND PLANNING OF ALL CARE FOR THE CLIENT B. BE AWARE OF AND COMMITTED TO ACCEPTED STANDARDS OR PRACTICE FROM NURSING AND OTHER DISCIPLINES C. NOT CHANGE THE PLAN OF CARE FOR THE CLIENT D. BE IN CONTROL OF ALL INTERVENTIONS FOR THE CLIENT
BE AWARE OF AND COMMITTED TO ACCEPTED STANDARDS OF PRACTICE FROM NURSING AND OTHER DISCIPLINES
WHEN ESTABLISHING REALISTIC GOALS THE NURSE: A. BASES THE GOALS ON THE NURSE'S PERSONAL KNOWLEDGE B. KNOWS THE RESOURCES OF THE HEALTH CARE FACILITY FAMILY, AND CLIENT C. MUST HAVE A CLIENT WHO IS PHYSICALLY AND EMOTIONALLY STABLE D. MUST HAVE THE CLIENTS COOPERATION
B. KNOWS THE RESOURCES OF THE HEALTH CARE FACILITY FAMILY AND CLIENT
TO INITIATE AN INTERVENTION THE NURSE MUST BE COMPETENT IN THREE AREAS WHICH INCLUDE: A. KNOWLEDGE, FUNCTION, AND SPECIFIC SKILLS B. EXPERIENCE, ADVANCED EDUCATION AND SKILLS, C. SKILLS, FINANCES, AND LEADERSHIP D. LEADERSHIP, AUTONOMY AND SKILLS
A. KNOWLEDGE FUNCTION AND SPECIFIC SKILLS
COLLABORATIVE INTERVENTIONS ARE THERAPIES THAT REQUIRE: A. PHYSICIAN AND NURSE INTERVENTION B. NURSE AND CLIENT INTERVENTION C. CLIENT AND PHYSICIAN INTERVENTION D. MULTIPLE HEATLH CARE PROFESSIONALS
D. MULTIPLE HEALTH CARE PROFESSIONALS
Define: Atelectasis.
A lack of gas exchange within the alveoli - the collapse of part or (much less commonly) all of a lung
When discussing client care with a nurse’s aide, the nurse instructs the aide to report any coughing during meals in a client who recently experienced a stroke and requires feeding. In this situation the nurse is acting as a(n): A. Client advocate B. On-the-job trainer C. Delegator D. Educator
C. Delegator
The nurse prepares a client for a lumbar puncture. Before the start of the procedure the nurse is sure to: A. Have the client void B. Place the client in Sims’ position C. Premedicate the client with analgesics D. Insert a peripheral intravenous (IV) catheter
A. Have the client void
The nurse anticipates that a right-handed client with a fractured right arm will require assistance with activities of daily living. The skill the nurse is d demonstrating is: A. Cognitive skill B. Interpersonal skill C. Psychomotor skill D. Behavioral skill
A. Cognitive skill
A nurse provides counseling to a family in spiritual distress from a recent, but expected, family member death when implementing the following intervention: A. Obtaining a consult for a psychiatric clinical nurse specialist B. Praying with the family C. Reminiscing with the family D. Arranging for the chaplain to visit the family
C. Reminiscing with the family
The nurse requests a stimulant laxative for a client receiving an opioid around-the-clock. By making this request the nurse is demonstrating: A. Promoting client health B. Concern for safety C. Controlling adverse reactions D. Colleague health education
C. Controlling adverse reactions
For all clients admitted to a cardiac unit, in the unit policy and procedure manual it states: if client experiences chest pain, administer 1/150 grain nitroglycerine SL and obtain a STAT ECG. This is an example of: _____________
A protocol-care of clients with a select clinical problem.
The nurse is developing a plan of care for a client with chronic low back pain, who was admitted from the postanesthesia recovery room following back surgery. Appropriately sequence the following goals, starting with the goal the client should achieve first: 1. Stand at the bedside 2. Ambulate with assistance 3. Participate in rehabilitative physical therapy 4. Transfer to bedside commode
1. Stand at the bedside 4. Transfer to bedside commode 2. Ambulate with assistance 3. Participate in rehabilitative physical therapy
When determining a client's ability to perform instrumental activities of daily living, the nurse assesses the following skills (select all that apply): A. Ability to bathe oneself B. Ability to write checks C. Ability to feed oneself D. Ability to take medications E. Ability to cook meals
B. Ability to write checks D. Ability to take medications E. Ability to cook meals
The nurse provides a variety of indirect care activities, which include (select all that apply): A. Providing client counseling B. Documenting C. Delegating D. Administering medications E. Evaluating new products
B. Documenting C. Delegating E. Evaluating new products
IMPLEMENTATION BEGINS WHEN IN THE NURSING PROCESS? A. DURING THE ASSESSMENT PHASE B. IMMEDIATELY IN SOME CRITICAL SITUATIONS C. AFTER THERE IS A GOAL SETTING BETWEEN NURSE AND CLIENT D. AFTER THE CARE PLAN HAS BEEN DEVELOPED
B. IMMEDIATELY IN SOME CRITICAL SITUATIONS
AN EXAMPLE OF THE DIFFERENCE BETWEEN DIRECT CARE AND INDIRECT CARE IS THAT INDIRECT CARE: A. ACTIONS ARE AIMED AT MANAGING ENVIRONMENT AND OCUMENTATION B. MEDICATION ADMINISTRATION IS PERFORMED C. PSYCHOLOGICAL COUNSELING IS PROVIDED D. INTRAVENOUS INFUSION HAS BEGUN
A. ACTIONS ARE AIMED AT MANAGING ENVIRONMENT AND DOCUMENTATION
A STANDING ORDER IS: A. PROTOCOL FOLLOWED DURING CARE OF CLIENTS WITH SELECT CLINICAL CONDITIONS B. PHYSICIAN ORDER DOCUMENTED ON EACH CLIENTS CHART C. PREPRINTED DOCUMENTATION DIRECTING THE CONDUCT OF CLIENT CARE IN CERTAIN SETTINGS D. DOCUMENTATION WRITTEN AND SIGNED BY AN ADVANCED PRACTICE NURSE
C. PREPRINTED DOCUMENTATION DIRECTING THE CoNDUCT OF A CLIENT CARE IN CERTAIN SETTINGS
SOME NURSING ACTIVITIES MAY BE DELEGATED TO OTHER HEALTH CARE TEAM MEMBERS. THE NURSE MUST REMEMBER THAT - A. DELEGATION MAY REDUCE THE CLIENTS COST OF CARE B. THE DELEGATED PERSONNEL ARE RESPONSIBLE FOR THE CARE C. THE NURSE HAS THE PRIMARY RESPONSIBILITY FOR THE QUALITY OF CLIENT CARE D. DELEGATION OCCURS ONLY UPON A PHYSICIANS ORDER
C. THE NURSE HAS THE PRIMARY RESPONSIBILITY FOR THE QUALITY OF CLIENT CARE
INTERDISCIPLINARY CARE PLANS REPRESENT A. CONTRIBUTIONS OF ALL DISCIPLINES CARING FOR THE CLIENT B. ALL NURSING PERSONNEL HAVING INPUT IN THE CARE PLAN C. THE CLIENTS EXPRESSED WISHES AND ADVANCED DIRECTIVES D. PHYSICIANS AND NURSES WORKING TOGETHER TO DEVELOP A PLAN OF CARE
A. CONTRIBUTIONS OF ALL DISCIPLINES CARING FOR THE CLIENT
REASSESSMENT OF A CLIENT IS - A. UTILIZED WHEN NEEDED B. A CONTINUOS PROCESS C. UTILIZED WHEN A NEW MEDICAL PROBLEM IS IDENTIFIED D. UTILIZED ONLY IN EMERGENCY SITUATIONS
B. A CONTINUOS PROCESS
ENVIRONMENTAL FACTORS HEAVILY AFFECT A CLIENTS CARE. THE FIRST ENVIRONMENTAL CIENT CONCERN IS ALWAYS - A. SAFTEY B. FOOD AND FLUIDS C. ADEQUATE PAIN RELIEF D. LOCATION OF FIRE EXITS
A. SAFETY
AN OUT-OF-DATE CARE PLAN - A. REFLECTS A DISCHARGE OF THE CLIENT B. COMPROMISES THE QUALITY OF CARE C. ENSURES THE NURSING CARE WAS DELIVERED D. IDENTIFIES THE CLIENT RESPONSE WAS DELIVERED
B. COMPROMISES THE QUALITY OF CARE
GOALS CAN BE ACHIEVED BY PROVIDING AN ENVIRONMENT THAT IS - A. STIMULATING AND MOTIVATING B. ENCOURAGING DEPENDENCE C. GOAL DIRECTED BY THE NURSING STAFF D. RIGID AND NON FLEXIBLE
A. STIMULATING AND MOTIVATING
WHEN A NEW PROCEDURE IS NEEDED THE NURSE MAY OBTAIN INFORMATION FROM THE AGENCY'S - A. PROCEDURE MANUAL B. INFECTION CONTROL DEPARTMENT C. INSERVICE DIRECTOR D. NURSING SUPERVISOR
A. PROCEDURE MANUAL
Likely condition of a client at the end of therapy or of a disease process, including the degree of wellness and the need for continuing care, medications, support, counseling, or education.
expected outcome
Desired results of nursing actions, set realistically by the nurse and client as part of the planning stage of the nursing process.
goals
Objective that is expected to be achieved over a longer period of time, usually over weeks or months.
long-term goal
Written guidelines of nursing care that document specific nursing diagnoses for the client and goals, interventions, and projected outcomes.
nursing care plan
Process of designing interventions to achieve the goals and outcomes of health care delivery.
planning
Reason for choosing a specific nursing action that is based on supporting literature.
scientific rationale
Objective that is expected to be achieved in a short period of time, usually less than a week.
short-term goal
A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function.
client-centered goal
Therapies that require the combined knowledge, skill and expertise of multiple health care professionals.
collaborative intervention
Those actions that require an order from a physician or another health care professional
dependent nursing intervention
Individual, family or community state behavior or perception that is measured along a continuum in response to a nursing intervention
nurse-sensitive client outcome
The order of nursing diagnoses using notations of urgency and/or importance, in order to establish a preferential order for nursing actions
priority setting
Actions that a nurse initiates without direction from a physician or other health care professional.
independent nursing intervention
Process involving the attachment, penetration, and embedding of the blastocyst in the lining of the uterine wall during the early stages of prenatal development.
implantation
What nursing leaders and educators revised their curricula to reflect.
client-centered problems
Process in which the help of a specialist is sought to identify ways to handle problems in client management or in the planning and implementation of programs.
consultations
Tool used in managed care that incorporates the treatment interventions of caregivers from all disciplines who normally care for a client. Designed for a specific case type, a pathway is used to manage the care of a client throughout a projected length of stay.
critical pathway
Trade name for card-filing system that allows for quick reference to the particular need of the client for certain aspects of nursing care.
Kardex
Define Priority setting in the Nurse planning context.
the ordering of nursing diagnoses or client problems using notions of urgency and/or importance to establish a preferential order for nursing actions
Define nursing “cognitive shift”.
shifts in attention from one client to another during the conduct of the nursing process.
Define a “goal” in the context of nursing.
an aim, intent, or end - a broad statement that describes the desired change in a client's condition or behavior.
Define a nursing “expected outcome”
measurable criteria to evaluate goal achievement
What is a client-centered goal?
a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function.
What is a nursing-sensitive client outcome?
an individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention.
What are the seven guidelines for writing goals and expected outcomes?
client-centered, singular, observable, measurable, time-limited, mutual, and realistic.
Define independent nursing interventions.
interventions that the nurse initiates
Define dependent nursing interventions.
Physician-initiated interventions
What is a scientific rationale in nursing care plans?
is the reason that you chose a specific nursing action, based on supporting evidence.
What are Critical pathways?
multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition - usually outlined by physician.
Define Consultation.
a process in which you seek the expertise of a specialist, such as your nursing instructor, to identify ways to handle problems in client management or the planning and implementation of therapies.
Define nursing intervention.
A nursing intervention is any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes
Define direct care vs. indirect care.
Direct care interventions are treatments performed through interactions with clients. For example, a client receives direct intervention in the form of medication administration, insertion of an intravenous infusion, or counseling during a time of grief. Indirect care interventions are treatments performed away from the client but on behalf of the client or group of clients
Define A clinical guideline or protocol.
a document that guides decisions and interventions for specific health care problems or conditions.
Define standing order.
A standing order is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific clients with identified clinical problems.
Why would you reassess?
The reassessment helps you decide if the proposed nursing action is still appropriate for the client's level of wellness.
Define Activities of daily living (ADLs).
activities usually performed in the course of a normal day
Define Instrumental activities of daily living (IADLs)
"such skills as shopping, preparing meals, writing checks, and taking medications.
Define lifesaving measure.
a physical care technique that you use when a client's physiological or psychological state is threatened
Define counseling.
Counseling is a direct care method that helps the client use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships.
Define adverse reaction.
An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.
Define Preventive nursing actions.
Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care.
Define interdisciplinary care plans.
Interdisciplinary care plans are plans representing the contributions of all disciplines caring for a client.
Define Client adherence.
Client adherence means that clients and families invest time in carrying out required treatments.
What are the domains of nursing?
The Helping Role, The Teaching-Coaching Function, The Diagnostic and Patient-Monitoring Function, Effective Management of Rapidly Changing Situations, Administering and Monitoring Therapeutic Interventions and Regimens, Monitoring and Ensuring the Quality of Health Care Practices, Organizational and Work-Role Competencies
What are the purposes of Nursing Intervention Classification?
Standardization of the nomenclature (e.g., labeling, describing) of nursing interventions, Expansion of nursing knowledge, Development of nursing and health care information systems, Teaching decision making to nursing students, Determination of the cost of services provided by nurses, Planning for resources needed, Language to communicate the unique functions of nursing, Link with the classification systems of other health care providers.
What does NIC (Nursing Intervention Classification) do?
The NIC system developed by the University of Iowa helps to differentiate nursing practice from that of other health care professionals
What is NIC?
Nursing Intervention Classification
Define Activities of daily living (ADLs).
Activities of daily living (ADLs) are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing, brushing the teeth, and grooming
Define biofeedback.
Use biological measures (e.g., heart rate, blood pressure) as feedback to modify a body function.
Define adverse reaction.
An adverse reaction is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.
Define preventative nursing care.
Preventive nursing actions promote health and prevent illness to avoid the need for acute or rehabilitative health care.
Define Evaluation.
Evaluation, the final step of the nursing process, is crucial to determine whether, after application of the nursing process, the client's condition or well-being improves.
Why do you do nursing evaluations?
You conduct evaluative measures to determine if you met expected outcomes, not if nursing interventions were completed
Name the five steps of the nursing evaluation process.
(1) identifying evaluative criteria and standards, (2) collecting data to determine whether the criteria or standards are met, (3) interpreting and summarizing findings, (4) documenting findings and any clinical judgment, and (5) terminating, continuing, or revising the care plan.
Define A nursing-sensitive client outcome.
A nursing-sensitive client outcome is a measurable client or family state, behavior, or perception largely influenced by and sensitive to nursing interventions - Examples of nursing-sensitive outcomes include reduction in pain severity, incidence of pressure ulcers, and incidence of falls.
What is NOC?
Nursing Outcomes Classification (NOC), which provides a classification system of nursing-sensitive outcomes.
What is an NSPO?
Define nursing-sensitive patient outcomes (NSPOs).
What is the purpose of NOC?
The purposes of NOC are (1) to identify, label, validate, and classify nursing-sensitive client outcomes; (2) to field test and validate the classification; and (3) to define and test measurement procedures for the outcomes and indicators using clinical data
Define evaluative measures.
assessment skills and techniques that you perform them at the point of care when you make decisions about the client's status and progress.
What is the difference between assessment and evaluation?
The intent of assessment is to identify what if any problems exist. The intent of evaluation is to determine if the known problems have remained the same, improved, worsened, or otherwise changed.
Define standard of care.
A standard of care is the minimum level of care accepted to ensure high quality of care to clients.
Define quality improvement or performance improvement.
Quality improvement (QI) and performance improvement (PI) are interchangeable terms that describe an approach to the continuous study and improvement of the processes of providing health care services to meet the needs of clients and others
Define Outcomes management.
Outcomes management is a term for managing the individual clinical outcomes of clients as a result of prescribed treatments.
Define pathogen.
an infectious agent (infection doesn't have to occur)
Define colonization.
when a microbe invades host (grows but doesn't cause infection)
Define infection.
the entry and multiplication of an organism (infectious agent) in a host.
Define communicable disease.
an infectious disease transmitted directly from one another
Define symptomatic.
when pathogens multiply cause clinical signs & symptoms
Define asymptomatic.
when clinical signs & symptoms are not present
Name chain of infection.
infectious agent > reservoir > portal of exit > mode of transmission > portal of entry > host
Name some infectious agents.
bacteria, viruses, fungi, protozoa
Define reservoir.
where pathogen survives but doesn’t multiply
Name types of reservoirs.
food, oxygen, water, temps, pH, light
Name some portals of exit.
blood, skin, mucous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, transplacental
Define vector.
insect that transmits a virus by biting host
What is the most common mode of transmission in the health care setting?
the unwashed hands of a health care worker
What is bactericidal?
temperature or chemical, that destroys bacteria
Define mode of transmission.
the way that a disease organism gets from what host (or carrier) to another.
Define susceptibility.
individual degree of resistance to pathogen
Define inflammatory response.
protective reaction neutralizes pathogens and repairs body cells
Define normal flora.
micro's reside in body does not cause disease but maintains health
Why does inflammation occur?
cellular response to injury, infection, irritation
What are the steps in inflammatory response?
vascular & cellular responses, formation of inflammatory exudates, then tissue repair.
What are exudates?
fluid and cells that are discharged from body parts (urine, pus, serous fluids)
Define phagocytosis.
destruction & absorption (eating) of bacteria
Define leukocytosis.
an increase in the number of circulating WBCs,
Define serous.
a fluid that is clear (like plasma)
Define sanguineous.
a fluid that contains red blood cells
Define purulent.
a fluid that contains WBCs & bacteria
What is granulation tissue?
a weaker (than collagen) tissue that forms a scar
Define HAI.
health care-associated infections nosocomial or health acquired infection
Define iatrogenic infections.
HAI infections from diagnostic or therapeutic procedures
Define asepsis.
absence of pathogenic microorganisms
Define pathogenicity.
potency of disease producing ability in a microorganism
Define medical asepsis.
clean technique, procedures used to reduce number organisms present and prevent transfer of organisms
What is “standard precautions?”
prevention & control of infection
Define disinfection.
process that eliminates most microorganisms (except bacterial spores)
Define sterilization.
the complete elimination or destruction of microbes including spores
List some personal protective equipment.
gowns, respiratory protection, eye protection, gloves
Define epidemiology.
study of disease of humans & animals, cause & effect of disease
Define surgical asepsis?
sterile technique prevents contamination of open wound serves to isolate operative area from unsterile environment & maintaining a sterile field of surgery
Define a sterile field?
area free of microbes & prepared to receive sterile items
Why are patients facing increased risk for infection?
because of lower resistance to infectious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures
Define aerobic.
aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans, when compared with anaerobic organisms
Define anaerobic.
anaerobic bacteria thrive where little or no free oxygen is available
Define bacteriostasis.
lack of bacterial growth/multiplication
Define broad-spectrum antibiotics.
antibiotics that are relatively microorganism non-specific, killing a broad range of harmful and healthy bacteria
What is a carrier?
persons (or animals) who show no symptoms of illness but who have pathogens on or in their bodies that can be transferred to others
What is cough etiquette?
(1) education of health care facility staff, clients' families, and visitors; (2) posters and written material for health care facility or agency staff, clients, families, and visitors; (3) education on how to cover your nose/mouth when you cough, using a tissue, and the prompt disposal of the contaminated tissue; (4) placing a surgical mask on the client if it will not compromise respiratory function or is applicable, which may not be feasible in pediatric populations; (5) hand hygiene after contact with contaminated respiratory secretions; and (6) spatial separation greater than 3 feet away from persons with respiratory infections
Define edema.
the accumulation of fluid which appears as localized swelling
Discuss endogenous vs. exogenous infection.
endogenous infections are from microorganism within the body (gut flora), exogenous infections are infections introduced from outside the body
What is host resistance?
susceptibility of the host to infection by microorganisms
Define immunocompromised.
having an impaired immune system
Define necrotic.
having tissue death
Define suprainfection.
an infection that develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. When normal bacterial flora are eliminated, the body's defenses are reduced, which allows for disease-producing microorganisms to multiply, causing illness
Define suppurative.
puss-forming
Define systemic.
something (an infection) that affects the entire body instead of just a single organ or part
Define virulence.
ability to survive in the host or outside the body
What do microorganisms need to survive?
food, water, correct oxygen condition, pH, temperature, light
What are the three steps in the infectious process?
Incubation period (multiplying but asymptomatic), prodromal stage (vague symptoms, fatigue), illness stage (classic symptoms), convalescence (recovering)
What are four parts of assessing risk of infection.
review of past disease, travel history; immunizations and vaccinations; status of defense mechanisms; patient susceptibility
Define epidermis.
The outer layer of skin.
Define dermis.
The dermis is a thicker (under) skin layer containing bundles of collagen and elastic fibers to support the epidermis. Nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles course through the dermal layers.
Define cuticle.
The fold of skin cover the base of the nail.
Define lunela.
The nail’s crescent-shaped white area.
What do the buccal glands do?
They are in the mucosa lining the cheeks and mouth maintain the hygiene and comfort of oral tissues.
Define mastication.
Chewing.
What is gingivitis?
Gum inflammation.
Why is hygiene important?
For comfort, safety and well-being of patient.
Define diabetic neuropathy.
Lack of feeling in feet.
Discuss thrush nursing treatment.
Saline rinse every two hours.
Define Lordosis.
Opposite of hump-backed.

Define Ischemia.
Lack of blood flow. Ischemic areas have no blood flow.
Define atelectasis.
partial or complete collapse of the lung.
Define erythema.
Red spot from laying on (etc) a spot.
Define Orthostatic hypotension.
Low blood pressure from changing positions rapidly.
How might you prevent atelectasis?
Turn, cough, deep breathe - every one to two hours.
Define deep vein thrombosis.
A blood clot that gets stuck. “DVT”
What is the difference between complete and partial bed bath?
Complete is all care-give done. Partial is when the client performs part of the bath themselves.
Define sink sponge bath.
Sponge bath at the sink: Involves bathing from a bath basin or sink with the client sitting in a chair. Client is able to perform a portion of the bath independently.
Define tub bath.
Tub bath: Involves immersion in a tub of water that allows more thorough washing and rinsing than a bed bath
Define shower.
Shower: Client sits or stands under a continuous stream of water.
How do you assess for circulation?
Blanching for capillary refill. (less than 3 seconds), skin temperature, skin color, distal pulse
How do you check movement?
mobility of distal digits.
How do you check for sensory?
Do you feel any numbness or tingling? Can you feel touch?
What do you assess in cast & traction care? (or any limb injury)
CMS (Circulation, movement, sensory)
What is a main (patient-centered) benefit of a bag bath?
Infection control.
What is the minimum fluid intake per day for bowel function, kidney function, etc.?
1500 ml per day
How frequently do you remove TED hose?
30 minutes every 8 hours.
Define effleurage.
the guiding strokes of a massage.
Define maceration.
becoming softened by soaking in a liquid.
What does the ADA identify as risk conditions associated with increased risks of amputation?
peripheral neuropathy; altered biomechanics; evidence of increase pressure from callus, erythema, or hemorrhage under a callus,; limited joint mobility, bony deformity, or severe nail pathological condition; peripheral vascular disease; a history of ulcers or amputation.
Define edentulous.
Without teeth.
Define stomatitis.
inflammation of the mucous membrane of the mouth.
Define enucleation.
surgically remove (a tumor or gland, or the eyeball) intact from its surrounding capsule.
How do you assess for DVT?
Measure the calf region - compare to the other side. Also assess for pain, redness and swelling.
Define Body Mechanics.
Body mechanics is a term used to describe the coordinated efforts of the musculoskeletal and nervous systems.
Define Body Alignment.
Body alignment means that the individual's center of gravity is stable.
Define Friction.
Friction is a force that occurs in a direction to oppose movement.
Define Pathological fractures.
Pathological fractures are fractures caused by weakened bone tissue.
Define synostotic joint.
The synostotic joint refers to bones jointed by bones. No movement is associated with this type of joint, and the bony tissue that forms between the bones provides strength and stability.
Define cartilaginous joint.
In the cartilaginous joint, or synchondrosis joint, cartilage unites bony components. This type of joint allows for bone growth while providing stability.
Define fibrous joint.
The fibrous joint, or syndesmosis joint, is a joint in which a ligament or membrane unites two bony surfaces.
Define synovial joint.
The synovial joint, or true joint, is a freely movable joint in which contiguous bony surfaces are covered by articular cartilage and connected by ligaments lined with a synovial membrane.
Define cartilage.
Ligaments are white, shiny, flexible bands of fibrous tissue binding joints together and connecting bones and cartilages.
Define Tendons.
Tendons are white, glistening, fibrous bands of tissue that connect muscle to bone.

Define cartilage.
Cartilage is nonvascular, supporting connective tissue located chiefly in the joints and thorax, trachea, larynx, nose, and ear.
Layers of skin?
Stratum corneum, epidermis, dermis
Integumentary assessment consists of checking:
Skin condition; presence of ulcers or lesions, mobility, nutrition/fluid status, pain, existing wounds (appearance or character), wound culture, photo (consent needed), body fluids.
Define pruritis.
Itching.
define urticaria.
Hives
Define wheal.
small raised area under skin, soft or firm.
Define Erythema.
reddened skin
Define Cellulitis.
cell inflammation
Define necrosis.
cell/tissue death
Define exacerbation.
worsening
Define Pressure ulcer.
a sore caused by ischemia (caused by pressure). Pressure intensity x duration - affected by tissue tolerance.
Define shear.
s skin tear due to friction.
What are risk factors for developing pressure ulcers?
impaired sensory perception, alterations in consciousness, impaired mobility, shear, friction, moisture.
Where are the common sites for pressure ulcers?
sacrum, heels, elbows, lateral malleolus (ankle), greater trochanter (hips), ischial tuberosities (pelvic), Maybe even head, elbows, ears
What are the 2 common predictor tests for risk for pressure ulcers?
Norton scale, Braden Scale.
How do you classify pressure ulcers?
"Stage 1 (skin intact, but abnormal reactive hyperemia), Stage 2 (tear in skin, see lower areas of skin) Stage 3 (skin gone, subcu layer visible) Stage 4 (bone, tissue or muscle visble). Unstageable ""eschar"" tissue covers the wound - can't see depth of injury."
What are risk factors for poor wound healing?
Pg. 1290, Nutrition; tissue perfusion; infection; age; psychological impact of wouns.
Define UAP.
Unlicensed assistive personnel
What are the four types of traumatic wounds?
Contusion, abrasion, laceration, puncture
Which can you assume is worst? Contusion, abrasion, laceration, puncture
Puncture because you can't see how deep.
In what ways do you evaluate a wound?
Amount of bleeding, size, Superficial vs. Deep
What do you evaluate in stable-setting wounds?
Describe drainage (Serous, sanguineous, serosanguineous, purulent); closure (staples, sutures, open); palpation of wound; may or may not have to get or review woods cultures.