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92 Cards in this Set
- Front
- Back
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What is the definition of health? |
The World Health Organization states that Health is :The state of complete physical, mental, and social well-being; not just the absence of disease or infirmity. |
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Name some wellness behaviors (health promotion). |
- good nutrition - exercise - good night's sleep |
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What is health protection and name some examples. |
Making individual changes in lifestyle and making choices that affect ones health prospects. Ex. smoking cessation (to avoid lung cancer), exercising (to avoid weight gain), eating low cholesterol food (to avoid high cholesterol). |
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What is health promotion? |
Individual lifestyle choices motivated by the desire to increase well being, not to avoid disease. |
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What are the three levels of health protection? |
Primary Secondary Tertiary |
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What is the primary level of health protection? Give an example. |
To prevent or slow the onset of disease. Ex. eating healthy, using sunblock, seatbelts, vaccines, etc. |
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What is the secondary level of health protection? Give an example. |
Screenings, detecting and treating illness in it's early stages. Ex. Self breast /testicular exams, screenings for Tb, BP, DM, mammograms, etc. |
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What is the tertiary level of health protection? Give an example. |
Stopping disease progression & returning to pre-illness state & rehab. Ex. hip replacement (rehab), MI (antihypertensive meds). |
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What is the first step in the nursing process? |
Assessment |
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What is the second step in the nursing process? |
Nursing diagnosis. |
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What are the steps in the nursing diagnosis? |
1. Analyze & interpret the assessment data 2. Use critical thinking skills 3. identify patterns in the data 4. draw & verify conclusions about patient's health 5. write the diagnostic statement 6. prioritize the problems 7. Involve the patient/ family as much as possible |
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What is the definition of the nursing diagnosis as written by NANDA? |
A clinical judgement about an individual, family or community responses to actual or potential health problems/ life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. |
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How do you recognize a nursing diagnosis? |
- It's a statement of a person's health status that nurses can identify, prevent or treat independently. - it's stated in terms of human responses to disease or injury and can be a problem or strength. - the responses are physiological, psychological, developmental, sociocultural or spiritual |
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Give an example of a nursing diagnosis as compared to a medical one. |
A medical diagnosis may be "renal failure", but the nursing diagnosis would be "excessive fluid volume" (a physiological response). A medical diagnosis may be "stroke" but the nursing diagnosis would be "impaired verbal communication, risk for falls, impaired movement", etc. |
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What are the 5 types of nursing diagnoses? |
1. Actual 2. Risk 3. Possible 4. Syndrome 5. Wellness (WRAPS) |
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Maslow's style of a hierarchy of needs can be used with prioritizing nursing interventions. Give examples of kinds of high, medium and low priority |
- high priority may be life threatening issues - medium priority may not be a direct threat to life but may cause destructive physical or emotional changes - low priority requires minimal supportive nursing intervention |
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What is planning? |
- The 3rd step of the nursing process, after the nursing diagnosis - requires critical thinking - decision making - problem solving techniques - is through communication and ongoing consultation - requires working closely with patients, families, and other health professionals |
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What does planning involve? |
1. setting priorities 2. ID the patient centered goals 3. expected outcomes 4. prescribing individualized nursing interventions |
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Can an RN delegate a nursing plan? Why or why not? |
No, because a professional nurse is responsible for care planning. It must have - realistic goals - effective nursing orders - accurate & complete assessment data - correctly ID - a priority list |
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How many kinds of planning are there and what are they? |
1. formal planning 2. informal planning 3. ongoing planning 4. initial planning 5. discharge planning 6. Short-term and Long Term goals |
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What is formal planning? |
- it is conscious and deliberate - involves critical thinking, decision making & creativity - the nurse works closely with the patient and family to derive desired outcomes - end result is a holistic plan of care that addresses the patients unique strengths |
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What is informal planning? |
- occurs while the nurse is performing other steps - making mental notes or plans Ex. while giving care to a patient, the nurse notices the patient isn't achieving good pain relief, so the nurse makes a mental note to notify the patient's doctor. |
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What is initial planning? |
- begins with first client contact - written as soon as possible after - initial assessment Ideally, the nurse who does the initial assessment should be the one to initiate the care plan and develop the comprehensive care plan. |
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What is ongoing planning? |
- changes made in the plan - evaluation of the client's responses to care - new data and information is obtained Ex. patient admitted has a hard time falling asleep the first night. NDx would be: disturbed sleep pattern r/t unfamiliar environment & pain |
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What is discharge planning? |
- planning for self care and continuity of care after - begins with initial assessment - all clients need discharge planning - requires collaboration with other caregivers; RN, PT, OT, hospice, rehab, MD, etc. |
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What is a long term goal and give an example. |
To be achieved over a longer period of time. A week, a month or more. |
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What is a short term goal and give an example. |
To be achieved within a few hours or a few days. Ex. day surgery. |
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When should a nurse be concerned about the urine output of a patient. |
When it's below 30mL/ hour. |
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What is specific gravity and what is the normal range for urine. |
Essentially, it is the concentration of the urine. Normal range is 1.002 to 1.028 |
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What is over hydration? |
When the specific gravity is below 1.000. Could potentially be caused by diabetes or diuretics |
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What is dehydration? |
When specific gravity is over 1.028. It is helpful to remember that specific gravity is high, such as the statement "high and dry". |
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How is a freshly voided urine specimen collected? |
For women, it is collected in a "hat" under the toilet seat and for men, it is collected in a urinal. |
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How is a sterile specimen collected from a Foley? |
- clamp drain below specimen port - wear gloves and swab port - insert a sterile needle-less access device and a syringe to remove the specimen and place in a sterile container. - remove clamp - never disconnect the catheter and never remove the specimen directly from the bag for a sterile catch. |
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What are the steps for collecting a 24 hour specimen? |
- the very first urine is discarded and then collection is begun - use a large container - post signs and tell patient & family - if one specimen is missed, it needs to be restarted |
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Can a bladder be palpated? |
Only if it is full. An empty bladder cannot be palpated. |
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What is the position for placing a catheter? |
Dorsal recumbent position. |
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What are the reasons for having an indwelling urinary catheter? |
- acute urinary retention - surgery - need for accurate measurement of urinary output in the critically ill - assist in healing of open sacral or perineal wounds in incontinent patients - patients in traction |
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Why are indwelling urinary catheters not used for incontinence? |
It can introduce microbes into the urethra. It is a leading cause of nosocomial infections. An indwelling catheter is only used as a last resort. |
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What are the steps for discontinuing a urinary catheter? |
- is not a sterile technique - wear gloves - position patient (DR for women, supine for men) - place water proof drape under the patient - insert appropriate sized syringe to deflate balloon by aspirating fluid - withdraw catheter, measure urine and discard bag and tubing - patient should void in 6-8 hours or MD should be alerted |
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What is urinary incontinence? |
lack of voluntary control over urination |
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What are the types of urinary incontinence? |
- functional (can't get to a toilet) - overflow (loss of urine over distention of bladder) - reflex (neural deficits, ie spinal cord injury) - urge (involuntary leakage with urgency) - total (continuous loss of urine) - stress (involuntary loss that occurs with increased intra-abdominal pressure like sneezing, coughing, etc.) - enuresis (involuntary wetting after age 6) - nocturnal enuresis (bed wetting after age 6)
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What is dilute? |
Urine with with a specific gravity of less than 1.000 |
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What is concentrated urine? |
Urine with a specific gravity of greater than 1.028 |
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What is dysuria? |
difficult or painful urination |
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Define enuresis. |
Involuntary urination. |
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Define frequency in regards to urination. |
Increased incidence of voiding. |
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What is hematuria? |
Blood in urine |
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What is incontinence? |
Inability to hold urine in the bladder |
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What is nocturia? |
Urination at night |
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What is micturition? |
Urination |
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What is oliguria? |
Decreased urine production (less than 30mL |
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What is polyuria? |
Excessive urination |
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What is retention in regards to urine? |
Unable to urinate, holding urine in the bladder. |
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What is urgency? |
Sudden need to void |
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What are the foods to help prevent a UTI? |
- foods high in protein - cranberry juice - yogurt - blueberries |
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Name a few facts about Judaism. |
- one of the oldest in the world - the original language is Hebrew - sacred text is the Torah - spiritual leader is a Rabbi - place of worship is a synegogue |
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Name a few facts about Roman Catholicism. |
- a branch of Christianity - belief in the holy trinity - belief in the divinity of Jesus Christ - belief in the authority of the Pope - belief in Saints - belief that the Eucharistic Bread is the true body of Christ when blessed by a priest |
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Name a few facts about Protestantism. |
- a branch of Christianity - 2 sacraments - baptism & communion (as opposed to the 7 Catholic sacraments) - started in England in the 16th Century |
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Name a few facts about Hinduism. |
- belief in reincarnation - cows are the symbol of life and may never be killed - use the greeting "namaste" - founded yoga |
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Name a few facts about the Islam religion. |
- based on revelations received by Mohammed - followers are called Muslims - sacred text is the Quran - their god is "Allah" |
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Name a few facts about Jehovah's Witnesses. |
- was founded in 1879 by Charles Taze Russell - very active in evangelism - do not believe in Hell - believe a blood transfusion is against God and will be punished if one is received. |
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What are the barriers to spiritual care? |
- lack of awareness of spirituality in general - lack of awareness of your own spiritual belief - differences in spirituality between nurse and patient - fear that your knowledge base is insufficient - fear of where spiritual discussions may lead |
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What is the primary source for a patients spiritual assessment? |
The patient's beliefs. |
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What does spiritual care demand? |
Nonjudgemental attitude and open thinking |
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What is loss? |
The undesired change or removal of a valued object, person or situation. |
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What is grief? |
Physical, psychological and spiritual responses to a loss. |
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What is mourning? |
An action associated with grief. |
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What is bereavement? |
Mourning and adjustment time following a loss. |
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What can be a nursing diagnosis for the terminally ill patient? |
- denial - hopelessness - social isolation - spiritual distress |
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What are the five stages of grief? |
- denial - anger - bargaining - depression - acceptance |
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What does a nurse do to help families grieve? |
- provide emotional support immediately after the death - provide grief education - it is normal for the nurse to feel grief when a patient dies. The nurse must take care of herself. |
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What are the goals of hospice care? |
to provide comfort, relieve physical, emotional, and spiritual suffering, and promote the dignity of terminally ill persons. |
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What is the uniform determination of death act? |
An individual who has sustained either 1. irreversible cessation of circulatory and respiratory functions or 2. irreversible cessation of all functions of the entire brain including the brain stem ....is dead |
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What key premises is hospice care based on? |
1. the quality of life is as important as the length of life 2. those who are terminally ill should be allowed to face death with dignity and surrounded by the comfort of their homes and families. |
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What is the difference between direct and indirect care interventions? |
Direct care interventions involve interaction with the patient like physical care. Indirect care interventions are performed away from the patient but on behalf of the patient such as making referrals or advocacy. |
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What is the difference between dependent, independent and interdependent interventions? |
The independent interventions are the ones the nurse can delegate and develop. The dependent interventions are prescribed by the Dr. and carried out by the nurse. The interdependent interventions is where everyone pitches in. |
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What are the steps in planning interventions? |
1. review the nursing diagnosis 2. review the desired client outcomes 3. identify several interventions/ actions 4. choose the best interventions for this client 5. individualize the standard interventions |
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What are some important characteristics of effective nursing interventions? |
- if they are based on evidence-based practices - if they are personalized |
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What are the components of a nursing order? |
- date - subject - action verb - times and limits - signature |
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What are the guidelines for selecting goals for interventions? |
- contextual awareness (is it right for the patient?) - credible sources (have I used valid sources? are they ethical?) - considering alternatives (which action is most reasonable, why are the others not?) - analyzing assumptions (what biases do I have that affect my thinking?) - reflecting skeptically (are there others I have overlooked? could there be any ill affects?) |
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What is an assessment of constipation? |
It is defined as a decrease in frequency of bowel movements resulting in the passage of hard, dry stool. A nursing diagnosis may be 'dysfunction of gastrointestinal motility'. May need to add if it's increased, decreased ineffective or absent. |
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What would be included in patient care regarding constipation? |
- narcotics can cause it - exercise is helpful and sometimes necessary - increase of fluid intake is essential - increase of bulk fiber (vegetables, fruit, etc) is also very helpful |
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What risk factors involve constipation? |
- lack of exercise (or bed rest) - lack of fluids - lack of bulk fiber in the diet - medications such as narcotics - surgery |
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What interventions are there for constipation? |
- increase fluid intake - increase bulk fiber intake - laxatives - encourage exercise - patient education - enema |
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What is included for patient education for a patient with diarrhea? |
- teaching prevention such as hand-washing - limit foods containing caffeine such as coffee, tea and chocolate - they are diuretics - A BRAT diet is good when resuming foods (Bananas, rice, apples and toast) - some meds cause it - yogurt or probiotics is good |
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What is a paralytic ileus and what causes it? |
It is a paralyzed intestine, loss of peristalsis or obstruction. It is often caused by surgery. |
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How do you assess for a paralytic ileus? |
Listen for bowel sounds for 5 minutes. If you hear nothing, that may be the case. |
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What are the interventions for a patient with paralytic ileus? |
There is sometimes a NG tube placed to help remove secretions that can make the patient uncomfortable until peristalsis returns. |
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What is fecal occult blood testing? |
It means testing for blood in the stool. It may not be able to be seen by the naked eye, so it is tested for. |
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What can cause an inaccurate result in a fecal occult blood test? |
- a diet high in red meat - false positive - iron supplements - false positive - if the patient takes a high dose of vitamin C, it could be a false negative - if the patient is a menstruating female, some of the blood may inadvertently get in the sample |
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What is happening during irrigation of a colostomy? |
Essentially, fluid is being placed inside the large intestine, where it helps to clean and evacuate stool from the large intestine. It drains back out and takes about 30 minutes to complete. |
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What are the steps to irrigating a colostomy? |
1. place IV pole near location 2. choose location (toilet, commode, chair) 3. prepare irrigation container - fill with warm water and prime tubing 4. hang solution near patient's shoulder 5. wash hands, put on clean gloves 6. remove colostomy bag 7. empty colostomy bag in toilet and dispose 8. assess stoma and apply irrigation sleeve 9. lubricate cone 10. open irrigation sleeve and place cone in stoma 11. open clamp on tubing to allow flow of water 12. adjust flow for comfort 13. when all the water has gone in, clamp tube and remove cone 14. wrap cone until it can be cleaned or disposed of 15. close top of irrigation sleeve with clamp 16. ask patient to remain seated until all contents have evacuated. 17. when complete rinse and remove irrigation sleeve 18. cleanse stoma, apply new colostomy bag 19. clean irrigation sleeve 20. remove gloves and wash hands 21. assist patient back to bed |
