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129 Cards in this Set
- Front
- Back
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DEFINE DIAGNOSIS
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A FORMAL STATEMENT OF THE PT'S HEALTH STATUS USING STANDARDIZED LISTING OF DIAGNOSTIC TERMINOLOGY
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WHAT DOES NANDA STAND FOR?
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NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION
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WHAT ARE DIAGNOSTIC LABELS?
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THE STANDARDIZED LISTING OF DIAGNOSTIC TERMINOLOGY APPROVED BY NANDA
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DEFINE NURSING DIAGNOSIS
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A CLINICAL JUDGEMENT ABOUT INDIVIDUAL, FAMILY OR COMMUNITY RESPONSES TO ACTUAL OR POTENTIAL HEALTH PROBLEMS/LIFE PROCESSES
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WHAT ARE THE FIVE STEPS OF DIAGNOSIS?
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1. ANALYZE/INTERPRET DATA 2. CLUSTER DATA AND IDENTIFY PT PROBLEMS 3. FORMULATE NURSING DIAGNOSES, BOTH ACTUAL AND POTENTIAL 4. PRIORITIZE NURSING DIAGNOSES 5. DOCUMENT NURSING DIAGNOSES
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WHAT DOES A MEDICAL DIAGNOSIS IDENTIFY?
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THE DISEASE PROCESS
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GIVE EXAMPLES OF MEDICAL DIAGNOSIS
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CHF, COPD, DIABETES
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WHAT DOES A NURSING DIAGNOSIS IDENTIFY?
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AN ACTUAL OR POTENTIAL PROBLEM BASED ON THE HEALTH ASSESSMENT
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GIVE SOME EXAMPLES OF WHAT A NURSE CAN INDEPENDENTLY AND LEGALLY TREAT (NURSING DIAG.)
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CONSTIPATION, ANXIETY
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IS PNEUMONIA A NURSING DIAGNOSIS?
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NO, A MEDICAL DIAGNOSIS, A NURSE CANNOT LEGALLY TREAT PNEUMONIA WITHOUT A DOCTOR'S ORDER
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WHAT NURSING DIAGNOSIS IS PRESENT AT THE TIME YOU MAKE AN ASSESSMENT AND ALSO ASSOCIATED SIGNS AND SYMPTOMS ARE PRESENT?
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ACTUAL NURSING DIAGNOSIS
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WHAT NURSING DIAGNOSIS IS LIKELY TO DEVELOP IF THE NURSE DOES NOT INTERVENE AND RISK FACTORS ARE PRESENT?
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RISK NURSING DIAGNOSIS
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WHAT TYPE OF NURSING DIAGNOSIS IS USED IF A PT. WANTS A HIGHER LEVEL OF WELLNESS?
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WELLNESS DIAGNOSIS
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WHAT IS A LABEL?
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A DIAGNOSIS
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WHAT IS THE NURSING DIAGNOSTIC LABEL FOR A PT THAT IS OVERWEIGHT?
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NUTRITION: IMBALANCED, MORE THAN BODY REQUIREMENTS
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WHAT IS THE NURSING DIAGNOSIS LABEL FOR A PT THAT IS UNABLE TO WALK?
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PHYSICAL MOBILITY, IMPAIRED OR WALKING IMPAIRED
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WHAT IS THE NURSING DIAGNOSIS LABEL FOR A PT THAT HAS PRESSURE ULCERS?
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SKIN INTEGRITY, IMPAIRED OR TISSUE INTEGRITY, IMPAIRED OR INFECTION, RISK FOR
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WHAT IS THE NURSING DIAGNOSIS LABEL FOR A PT THAT HAS ABD PAIN FROM SURGERY?
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PAIN, ACUTE
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GIVE EXAMPLES OF RELATED FACTORS OF THE NURSING DIAGNOSTIC LABEL, ACTIVITY INTOLERANCE
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PROLONGED IMMOBILITY (BED REST TIMES 1 WEEK), EXPERIENCING PAIN (BAD TOOTH ACHE), CARDIOVASCULAR OR RESPIRATORY PROBLEM, DEPRESSION/ANXIETY, MUSCULOSKELETAL DISORDER (WEARING A CAST ON ONE LEG)
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WHAT IS ETIOLOGY?
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THE CAUSE, OR FACTORS
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WHAT COULD BE RELATED FACTORS (ETIOLOGY) OF THE NURSING DIAGNOSIS SELF CARE DEFICIT (BATHING)?
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COGNITIVE DEFICITS (ALZHEIMERS) OR 2 BRIKEN WRISTS, DEPRESSION
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WHAT COULD BE RELATED FACTORS (ETIOLOGY) OF THE NURSING DIAGNOSIS RISK FOR BODY DISTURBANCE?
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MASTECTOMY, OBESITY, RASH ON FACE
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WHAT COULD BE RELATED FACTORS (ETIOLOGY) OF THE NURSING DIAGNOSIS FLUID VOLUME DEFICIT?
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DEHYDRATION CAUSED BY VOMITING, DIARRHEA OR BLOOD LOSS-HEMORRHAGE OR DIURETIC USE
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WHAT DOES A BASIC THREE PART NURSING DIAGNOSIS PES FORMAT STAND FOR?
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P=PROBLEM, E=ETIOLOGY, S=SIGNS AND SYMPTOMS
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BASIC TWO PART NURSING DIAGNOSIS HAS WHAT TWO PARTS?
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P=PROBLEM AND E=ETIOLOGY
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WHEN WRITING A NURSING DIAGNOSIS, WHAT THREE PARTS DO YOU NEED?
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LABEL, ETIOLOGY AND DEFINING CHARACTERISTICS
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IN THE FOLLOWING NURSING DIAGNOSIS WHAT IS THE ETIOLOGY? ACTIVITY INTOLERANCE RELATED TO CHANGES IN OXYGEN TRANSPORT MANIFESTED BY (OR EVIDENCE BY) SHORTNESS OF BREATH ON EXERTION?
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LOW HEMOGLOBIN
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IN THE FOLLOWING NURSING DIAGNOSIS WHAT IS THE PROBLEM? ACTIVITY INTOLERANCE RELATED TO CHANGES IN OXYGEN TRANSPORT MANIFESTED BY (OR EVIDENCE BY) SHORTNESS OF BREATH ON EXERTION?
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ACTIVITY INTOLERANCE
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IN THE FOLLOWING NURSING DIAGNOSIS WHAT IS THE SIGNS/SYMPTOMS? ACTIVITY INTOLERANCE RELATED TO CHANGES IN OXYGEN TRANSPORT MANIFESTED BY (OR EVIDENCE BY) SHORTNESS OF BREATH ON EXERTION?
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SHORTNESS OF BREATH ON EXERTION
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IF THERE ARE NO SIGNS AND SYMPTOMS AND THE PT IS AT RISK FOR PROBLEMS, WHAT NURSING DIAGNOSIS WOULD YOU CHOOSE?
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POTENTIAL NURSING DIAGNOSIS OR RISK NURSING DIAGNOSIS
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POTENTIAL OR RISK DIAGNOSES ARE WRITTEN IN ? PART STATEMENT
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TWO PART STATEMENT
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GIVE ME A TWO PART STATEMENT RELATED TO A RISK FOR CONSTIPATION
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RISK FOR CONSTIPATION RELATED TO LACK OF FIBER IN THE DIET
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GIVE ME A TWO PART STATEMENT RELATED TO A RISK FOR IMPAIRED SKIN INTEGRITY
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RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO COMPLETE BED REST
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WRITE A COMPLETE DIAGNOSTIC STATEMENT FOR: CVA PT IS UNABLE TO FEED HIMSELF & HAS LOST 5LBS IN 20 DAYS
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SELF CARE DEFICIT RELATED TO HEMIPARESIS (CVA) MANIFESTED BY INABILITY TO FEED SELF OR ALTERATION IN NUTRITION LESS THAN BODY REQUIREMENTS RELATED TO HEMIPARESIS MANIFESTED BY 5 LB. WEIGHT LOSS
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What are the three types of quality evaluations?
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1. Outcome evaluation
2. Process evaluation 3. Structure evaluation |
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What does Outcome Evaluation focus on?
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demonstratable changes in the pt's health as a result of nursing care
Ex--Goal is to prevent development of a pressure ulcer. Did the client develop a pressure ulcer? |
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What does Process evaluation focus on?
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on how the care was give
Ex--How many times in the last 24 hrs did the staff turn the client every 2 hours; Was the client turned/re-positioned when he was out of bed in a wheelchair |
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What does Structure evaluation focus on?
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It focus on the setting in which the care is given- the environment, organizational, characteristics, staffing, equipment.
Ex--was ther adequate staff to provide care. |
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What is quality assurance?
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It is an ongoing process to assure quality health care.
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What are the five components of the evaluation process?
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*Collecting data related to the desired outcomes
*Comparing the data with outcomes *Relating nursing activities to outcomes *Drawing conclusions about problem status *Continuing, modifying, or terminating the nursing care plan. |
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An evaluation statement consists of two parts. What are they
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1.A Conclusion--which is a statement that the goal/desired outcome was met, partially met, or not met.
2. Supporting data--which are the list of client reponses that support the conclusion. For example Goal met: Oral intake 300mL more than output; skin turgor resilient; mucous membranes moist. |
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The Process of Implemetation is
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* Reassessing the pt
* Determining the caregiver's need for help * Implementing the nursing interventions * Delegation and supervising |
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Delegation is
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the transfer of responsibility for the performance of an activity from one person to another while retaining accountability for the outcome--ANA 1993
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What are the 5 right's of Delegation?
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Right task
Right circumstance Right person Right direction/communication Right supervision/Evaluation |
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What are the methods of Implementation?
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1.Assist/direct/perform activities of daily living(ADL'S), and other activities
2. Counsel,comfort,teach pt/family 3.Monitor for problems/complications 4. Carry out medical treatments and evaluate 5.Refer pt for care/follow-up/information 5. DOCUMENTATION |
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In order for a nurse to do the methods of implementation, what skills would she/he need to utilize?
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*Cognitive skills
*Interpersonal skills *Psychomotor skills |
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What are cognitive skills?
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To have adequate theorectical knowledge
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What are Interpersonal skills?
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To be able to communicate clearly
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What are Psychomotor skills
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To be physically able to carry a procedure out.
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Implementation means?
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Putting the care plan into ACTION...Doing what you said you were going to do!
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There are six factors in the text that influence individual hygiene practices, what are they?
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Culture, Religion, Environment, Developmental level, Health and energy, or personal preferences.
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When assisting with bathing and other hygeniec care, the nurse has the opportunity to assess (what) about hte person's skin?
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skin color, texture, turgor, temperature, intactness, and lesions.
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List some abnormal findings on the skin that are common. Hint(A-D-AD-A-E-H)
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An abrasion, excessive dryness, ammonia dermatitis, acne, erythema, hirsutism.
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What type of baths are giving cheifly for hygiene purposes?
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Cleaning Baths
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These baths are given for physical effects such as to soothe irritated skin
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Terapeutic baths.
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Please tell me ya'll know how to wash a vagina and a penis.
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If not, refer to pg 756 and 757 of Nursing Fundamentals. It's too long to type.
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During physical assesment of the feet, what are some common fot problems to be aware of when cleaning?
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Any calluses, corns, plantar warts (moderately contagious), fissures,tinea pedis, or an ingrown toe nail.
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What could be an abnormality of the nail during hygiene?...could also suggest a self care deficit
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Any swelling around the nail bed or an infected cuticle.
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What are abnormal findings associated with teeth?
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Carries, gingivitis, pyorrhea, plaque, tarter.
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These are signs that you should encourage increased fluids. (pertainig to signs of the mouth)
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Reddened or excortiated mucosa, excessive dryness of the buccal mucosa, or cheilosis. (cracking of the lips)
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What brushing techneique removes plaque and cleans under gingival margins?
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The sulcular technique
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wHAT IS ALOPECIA?
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HAIR LOSS
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What are abnormal findings to watch for when washing hair?
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Dandruff, Hair loss, Ticks, Pediculosis (lice), Scabies, and hirsutism
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When giving perineal care to a male, what is an extra intervention used?
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Retracting the foreskin to remove smegma ( cheesy discharge) Yuck.
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Before inserting a client's hearing aid, the nurse should:
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Turn the volume all the way down.
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WHEN WOULD YOU USE A TWO PART NURSING DIAGNOSIS?
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WHEN THE PATIENT IS AT RISK FOR SOMETHING TO HAPPEN
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WHAT ARE THE FOUR STEPS TO THE PLANNING PROCESS
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1. PRIORITIZE PROBLEMS/DIAGNOSES 2. FORMULATE GOALS/DESIRED OUTCOMES 3. SELECT NURSING INTERVENTIONS 4. WRITE NURSING INTERVENTIONS
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WHAT IS PRIORITY SETTING?
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A PROCESS OF ESTABLISHING A PREFERENTIAL SEQUENCE FOR ADDRESSING NURSING DIAGNOSES AND INTERVENTIONS
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WHAT IS CONSIDERED HIGH PRIORITY?
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LIFE-TREATENING
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WHAT IS MEDIUM PRIORITY?
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DOES NOT DIRECTLY THREATEN LIFE BUT MAY PRODUCE DESTRUCTIVE PHYSICAL OR EMOTIONAL CHANGES
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WHAT IS LOW PRIORITY?
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ARISES FROM NORMAL DEVELOPMENTAL NEEDS
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GIVE THREE WAYS YOU CAN PRIORITIZE WHEN SETTING PRIORITIES
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1. ACCORDING TO THREAT TO LIFE 2. ACCORDING TO MASLOW'S HIERARCHY OF HUMAN NEEDS 3. ACCORDING TO PATIENT PREFERENCE
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RANK PRIORITIES FROM ? TO ?
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HIGHEST TO LOWEST
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ARRANGE THE FOLLOWING ACCORDING TO PRIORITY:
-SELF CARE DEFICIT (BATHING) -ALTERED SEXUALITY PATTERN -CHRONIC LOW SELF ESTEEM -ALTERED NUTRITION: LESS THAN BODY REQUIREMENT |
1. ALTERED NUTRITION: LESS THAN BODY REQUIREMENTS
2. SELF CARE DEFICIT (BATHING) 3. CHRONIC LOW SELF ESTEEM 4. ALTERED SEXUALITY PATTERN |
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WHAT IS THE OUTCOME OF SETTING GOALS?
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THE DESIRED CHANGE IN THE PATIENTS HEALTH AFTER THE NURSING INTERVENTIONS
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WHAT ARE SHORT TERM GOALS?
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GOALS TO BE ACHIEVED IN A SHORT TIME, USUALLY LESS THAN A WEEK
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WHAT ARE LONG TERM GOALS?
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GOALS TO BE ACHIEVED OVER A LONG PERIOD, USUALLY OVER WEEKS OR MONTHS
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ARE GOALS AIMED TOWARDS CHRONIC DISEASES, SHORT TERM OR LONG TERM GOALS?
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LONG TERM GOALS
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WHAT IS THE MEANING OF ESTABLISHING EXPECTED OUTCOMES?
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EXPECTED OUTCOMES ARE THE SPECIFIC OBJECTIVES THAT LEAD TO ATTAINMENT OF GOALS
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WHEN WRITING EXPECTED OUTCOMES, WHAT FOUR THINGS SHOULD YOU TAKE INTO CONSIDERATION?
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1. PATIENT-CENTERED (PATIENT WILL....)
2. MEASURABLE AND OBSERVABLE 3. TIME-LIMITED 4. REALISTIC |
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IF A GOAL IS TO IMPROVE ACTIVITY TOLERANCE, WHAT MIGHT AN EXPECTED OUTCOME BE?
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1. BY THE END OF TWO DAYS PT WILL BE ABLE TO PERFORM OWN PARTIAL BATH AS EVIDENCED BY ABSENSE OF SOB OR
2. BY THE END OF TWO DAYS, PT VERBALIZES AND USES ENERGY CONVERSATION TECHNIQUES |
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WHAT ARE THE THREE TYPES OF NURSING INTERVENTION?
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INDEPENDENT AND DEPENDENT AND COLLABORATIVE INTERVENTION
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DEFINE INDEPENDENT INTERVENTION
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NURSE REQUIRED INTERVENTIONS THAT REQUIRE NO DIRECTIONS FROM OTHERS
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DEFINE DEPENDENT INTERVENTION
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PHYSICIAN-INITIATED INTERVENTIONS THAT REQUIRE PHYSICIAN'S ORDERS
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DEFINE COLLABORATIVE INTERVENTIONS
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REQUIRES EXPERTISE OF MULTIPLE HEALTH CARE PROFESSIONALS
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EXAMPLE OF COLLABORATIVE INTERVENTION
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USING OCCUPATIONAL THERAPIST
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WHAT HAPPENS DURING A NURSE INITIATED INTERVENTION?
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THE NURSE PROVIDES TEACHING MATERIALS
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WHAT HAPPENS DURING A PHYSICIAN INITIATED INTERVENTION?
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THE PHYSICIAN ADMINISTERS MEDICATION
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GIVE AN EXAMPLE OF WHAT HAPPENS DURING A COLLABERATIVE INTERVENTION?
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APPLY ARM SPLINT RECOMMENDED BY THE OT
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WHEN WRITING INTERVENTIONS, WHAT DO YOU NEED TO REMEMBER AND INCLUDE IN NURSING ORDERS?
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-MUST BE SAFE AND APPROPRIATE FOR INDIVIDUAL PT.'S AGE, HEALTH AND CONDITION
-ACHIEVABLE WITH AVAILABLE RESOURCES -CONGRUENT WITH PT.'S VALUES, BELIEFS, CULTURE -HOLISTIC -CONGRUENT WITH OTHER THERAPIES -BASED ON NURSING KNOWLEDGE OR OTHER SCIENTIFIC PRINCIPLES -WITHIN THE ESTABLISHED STANDARDS OF CARE -LEGAL PROFESSIONAL, INSTITUTIONAL |
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NURSING ORDERS NEED TO INCLUDE:
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WHAT IS DONE, HOW OFTEN, HOW MUCH, WHAT METHOD, WHO WILL PERFORM, BE CONCISE, ALL ORDERS SHOULD BE DATED AND SIGNED BY NURSE
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A NURSING CARE PLAN NOT ONLY COORDINATES NURSING CARE, BUT ALSO.....
(*HINT-TWO MORE THINGS) |
PROMOTES CONTINUITY OF CARE AND IS USED TO EVALUATE CARE
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A NURSING CARE PLAN IS DESIGNED TO HELP THE NURSE BY DOING WHAT THREE THINGS?
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1. LEARN & APPLY THE NURSING PROCESS
2. LEARN ABOUT THE PATIENT'S PATHOPHYSIOLOGY 3. LEARN YOUR NURSING INTERVENTIONS AND THEIR RATIONALES |
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WHAT ARE THE FOUR FORMATS OF THE NURSING CARE PLAN?
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STANDARDIZED, MULTIDISCIPLINARY, PROTOCOLS, CRITICAL PATHWAYS
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WHAT ARE PROTOCOLS?
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PREPLANNED/PREPRINTED COMMON ACTIONS REQUIRED FOR A PARTICULAR TEST/DIAGNOSIS/TREATMENT/SITUATION
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WHAT IS A STANDARDIZED FORMAT FOR A NURSING CARE PLAN?
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'A MODEL" TAKEN FROM YOUR TEXT BOOK, CARE PLAN BOOKS, COMPUTERIZED PLAN
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There are six links that make up the chain of infection:
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microorganism, reservoir, portal of exit, mode of tansmission, portal of entry into the host, and susceptibility of the host.
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What are some ways to prevent nosocomial infections?
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Hand hygiene, supporting defenses of a susceptible host ( make sure pt is getting physical needs met, food, water, sleep.), disinfecting or steralizing, isolation precautions, dispose of soiled equipment and supplies
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AN example of an active immunity is:
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Having an antigen to chx pox b/c you actively fought off the infection
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An example of passive immuntiy is:
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Antibodies received from mother by breastfeeding or immunizations.
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What is the difference b/w medical asepsis and surgical sepsis?
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Med asepsis is "clean" of most mirobes. Surgical Asepsis is free of all microbes.
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What is a nursing intervention that can break the chain of the microorganism?
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ensure that articles are correctly cleaned and disinfected or sterilized before use.
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What is a nursing intervention to break the chain of infection for a reservoire (source)
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Change dressings when they are soiled or wet?
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Who are the people at risk for infection?
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childdren, elders, diabetics, hiv pt's.
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Commonly the skin and mucous membranes are involved in a local infectious process, resulting in? (looking for S/S of infection)
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Localized swelling, redness, pain or tenderness, palpable heat, loss of function to body part affected.
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What is a sign of systemic infection?
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bacteremia.
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Examples of nursing Dx that may arise from the actual presence of an infection include the following:
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Potential complication of infection AEB fever
Acute Pain if client is experiencing tissue damage and discomfort EX on pg 680. |
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Why is it essential to have a change-or-shift report?
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to provide continuity of care for clients by providing the new caregivers a quick summary of the client needs and details of care to be given.
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What are some ways that a change-of-shift reports can be given?
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Written or orally, either face-to-face exchange or by audiotape recording./
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What is creativity as related to nursing?
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it is the thinking that results in the development of new ideas and products
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What is critical thinking?
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In the nursing practice it is a discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.
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What is inductive reasoning?
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Generalizations are formed from a swt of facts or observations.
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What is deductive reasoning?
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Reasoning from the general premise to the specific conclusion.
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What attitudes foster critical thinking?
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Independence, fair-mindedness, insight into egocentricity, intellectual humility, and intellectual courage. As well as integrity, perseverance, confidence, and curiosity.
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What is the definition of the nursing process?
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It is a systematic, rational method of planning and providing individualized nursing care.
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What are the phases of the nursing process?
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ADPIE or assessment, diagnosis, planning, implementation, and evaluation
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How does a nurse practice problem solving?
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The nurse obtains info that clarifies the nature of the problem and suggests possible solutions and choose the best one to implement.
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What steps does a nurse take to make decisions?
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1. Identify the purpose, 2. set the criteria, 3. weight the criteria, 4. seek alternatives, 5. examine alternatives, 6/ project, 7. implement, 8. eval the outcome.
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What can one do to develop their critical thinking?
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self assessment, tolerate dissonance and ambiguity, seek situations where good thinking is practiced, and create environments that support critical thinking
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In relation to the nursing process-Assessing is?
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collecting data, organizing it, validating it and documenting it.
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In relation to the nursing process- Diagnosing is?
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analyzing data, identifing problems, risk and strength, and formuating diagnosic statements.
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In relation to the nursing process- planning is?
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prioritizing problems, formulating goals, selecting nursing interventions, and writing them out.
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In relation to the nursing process- Implementing is?
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reassing the client, determining the nurses need for assistance, implementing the nursing interventions, supervise delegated care and documenting nursing activities.
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In relation to the nursing process- Evaluating is?
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Collecting date related to outcomes, compare data with outcomes, relate nursing actions to client goals and outcomes, drawing conclusins about problem status, continue modify or terminate the clients care plan.
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What are data collection methods?
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Observing, interviewing, & examining.
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Defiene cephalocaudal.
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A head to toe approach in which to conduct an examination.
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Why does the nurse validate data that he/she receives?
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To ensure that assessment data is complete, to ensure that the objective was met, and that the subjective data matches and to differentiate between cues and inferences.
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What are cues In relation to the nursing process?
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theya re subjective data that can be observed by the nurse
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What are inferences In relation to the nursing process?
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the nurses interpretation or conclusions based on cues.
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