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63 Cards in this Set

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What is assessment? Important to make sure data is? First step in? What is the purpose of assessment?
-obtaining baseline data from patient for a continuous health process
-accessible, communicated, & recorded -nursing process and professional role decision making - ID abnormalities, strengths, copings, and risks
What are some characteristics of the nursing process? (10) What is the goal of the outcome?
-Dynamic, cyclic, Patient centered,
Goal directed, Flexible, Problem & action oriented, Cognitive, Interpersonal, Holistic
-Patient at healthier level
What are the six steps in the nursing process?
ADPIE-T - Assessment, Diagnosis, Planning/Outcome, Implementation, Evaluation, Teaching
Explain the assessment portion of the nursing process. (7)
-This is where you collect data by reviewing chart, interview(free flow, open ended q's), health history(foundation leads to diagnosis), physical exam, functional assessment, consultation(with colleagues), and review of literature(evidence based).
Besides physiological data, what are some other types of data collected from the patient in Assessment?
Psychological, sociocultural, spiritual, economic, and life-style factors
What is the nursing diagnosis? How do you come up with one? (7)
- A nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs
-Interpret data, ID cues, make inferences and validate, compare defining chars with cues, identify relating factors, document
Which portion of the nursing process is a basis for the care plan?
Diagnosis
For the nursing process, what is planning based on? What does the nurse do in this stage? Give an example. What is very important for this stage? What are four keys to developing a good outcome?
-Assessment and Diagnosis - Sets measurable and achievable short- and long-range goals for this patient - Move patient from bed-chair 3x/day, maintain adequate nutrition, pain mgmt with meds - Document plan of care - Identify interventions, individualize pt, measurable & realistic, within time frame
Nursing implementation is based on? How is it implemented? (6) Most importantly?
-the care plan. -schedule and coordinate total health care, teamwork, supervise, work with family and pt, refer continuing care -document care provided
What is important to remember about nursing process evaluation?
Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed. AND DOCUMENT
Why is verbal and nonverbal cx important? What are some vocal cues of pt cx? How can you detect action cues from a pt? Example of object cues?
-will detect what pt is feeling and saying - quality of voice, tone, speed, intensity, inflection - body mvmnts, posture, facial expression, touch, eye contact - how they dress, are they dishovled?
What if you cx with a cultural person you don't know? What must be kept in mind about personal space? Distance for public, social, and personal?
ask them to improve cultural competence. - varies by culture - >=12ft, 4-12ft, 18in-4ft
Give description / example of the following cx techniques: Facilitation, Silence, Clarifying, Restating, Active Listening, Open Ended, Reflection, Humor. Which one is especially important? why?
-uhhuh, go on tell me more -may be awkward, but lets them gather thoughts - make sure i have this right -acknowledge feeling, encourage further discussion -pay attn, eye contact -Open -Echo back in form of q - in right context -Open-ended is better than yes/no - to get an expanded view of the problem
Give description or examples of the following cx techniques: Informing, Redirecting, Focusing, Sharing perceptions, Identifying themes, Sequencing events, Suggesting, Presenting Reality, Summarizing.
-involvement in health-care decisions -get back on track -inquire about specific area -bring up inconsistencies -make connection and focus on major theme -what happened before?next? end? -present alternative ideas, provide options -exaggerating/contradicting facts, help be more realistic -let me summarize what you've told me
How should you be communicating with every single patient? (3) Describe each.
-genuineness (open, honest, sincere), respect(person of worth and value, nonjudgmental), and empathy(understand feeling "this must be hard for you")
What are some cognitive, critical thinking skills to approach a situation? (5)
-Divergent thinking(viewpoints, distinguish differences), Reasoning (fact from truth), Reflection(exp & new evidence), Creativity(multiple approaches), Evidence based
How should you be deciding in the clinic?
with relevance, looking for cues, inferences, patterns, and abnormal data
What are the different types of problem solving skills? (4) explain each.
Reflexive thinking(things come auto with experience), Trial & error(random, not good in clinic), Scientific method(nursing process), Intuition(expert nurse with advanced decision skills)
What type of assessment skill is needed for a nurse to "do"?
Psychomotor skills
What are some interpersonal aspects of assessment?
It's a "feeling" process, need to develop caring relationship with attn to verbal/nonverbal cx
Why are ethical skills important in assessment?
- for responsibility and accountability, practice, patient advocacy, assure HIPAA
What is the difference between nursing's goal and medicine's goal?
-Nurses treat and diagnoses human responses to actual/potential healh problems(pain, respiratory difficulty, stabilize), Medicine diagnoses and treats disease.
Whats is the primary level of preventative care? Secondary? Tertiary?
-Focus on health promotion and illness prevention - focus on early detection, prompt intervention, and health maintenance - rehabilitation and extended care
Subjective vs. Objective?
S- what patient says, not measurable. O- measurable, what nurse observes
What are the four types of assessment? Explain each.
Complete ( head to toe, history & physical), Episodic (Problem oriented, or ongoing) Follow-up (status of id problem), Emergency ( ABC)
What are two subjective methods of data collection? What are some interviewing pitfalls? (6)
- Interview (Direct or indirect), Quesions (Open or closed) -Judging (approve/disapprove), Unwarranted reassurances (cliches), Stereotyping, Probing(why don't u do it more often), Advising
What are some objective methods of data collection?(4)
Observation, Use senses, look at pt and environment.
What are the four steps of physical assessment? Explain each.
Inspection, Palpation, Percussion, Auscultation
What are some data collection pitfalls? (5)
-Omitted, misinterpreted, and irrelevant data, poor cx, failure to follow up
What are two ways to validate your data?
-Compare subjective and objective data
-Validate data with patient/fam/records/tests/coworkers
As far as organizing patient data, what is: Cluster data? Maslows Hierarchy? Roy's Adaptation? NANDA-Unitary Person Framework?
-group data for nursing diag - pt basic needs(phys/saf,love/selfest/selfactual) - pt adapt(phys/selfcon/social/interdep) - 9 human responses(exchanging,cx, relat, val, choose, move, perceive, know, feel)
To prioritize data, what is: Primary? Secondary? Tertiary?
-life threatening problems(ABCs) - require prompt attn to prevent progression(MAA-U-AR) -important, but can wait (lack of knowledge, sleep)
What is to be included in documenting data?(3)
SOAPIE, narrative, EMR
What are some documentation tips?(12)
-brief & to the point, acceptable abbrev, legible, phrases, facts, no "normal", sequential, spelling, date/time/signature, dont skip lines
Nursing Diagnosis, based on assessment of a number of factors, gives nurses a common language with which to communicate nursing findings. The best description of a nursing diagnosis is: A)Used to eval the etiology of a disease B)A pattern of coping C)concise description of actual or potential health probs or wellness strenghts D)Patients percetpion of a satisfaction with his or her own health status.
C
Depending on the clinical situation, the nurse may establish one of four kinds of database. An episodic database is described as: A)including complete hh and full phys exam B)Concerning mainly one problem C)Eval of prev IDed pt D) Rapid collection fo data in conjunc with lifesaving measures.
B
What should ratio of HR to RR be for vitals?
4:1
Select the best description of an accurate assessment of a patient's pulse: A)count for 15 secs if pulse is regular B)begin counting with zero; count for 30 secs C)Count for 30 secs and multiply by 2 in all cases D)Count for 1 full minute; begin counting with zero
B
Select the best description for an accurate assessment of a patient's respirations: A) Count for a full minute before taking pulse B)count for 15 secs and multiply by 4 C) Count after informing pt where youa re in assess process D)Count for 30 secs following pulse assessment
D
What are the four stages of Nocioception?
-1-Transduction-response to noxious (painful) stimulus that results in tissue injury, 2-Transmission-moves from spinal cord to brain, 3-Perception-concsious awareness of pain via limbic sys 4-Modulation-pain message inhibited by downward pathways(lowers pain)
Compare Acute pain to Chronic pain.
Acute is short term, self limiting, predictable and dissipates after heal. Chronic is >6mo, cancer malignant, but can be non cancer (arthritis)and pain syndrome(consumes and incapacitates)
What is sensitization of pain? Action? Action example.
Prolonged exposure to noxious stimuli (part of chronic). - It's a protective mechanism during healing, but if persists, chronic pain can come. - lower pain leading to hyperalgesia(increased response to painful stimuli)
What are four types of Nociceptive pain? Also give pain quality of each.
Visceral(deep internal organ injury or stretching-ache,stab,cramp), Cutaneous(superficial somatic pain; skin or subQ-sharp,prick,burn) Somatic(blood vessels, tendon, joints, muscles bones-dull,ache,cramp) Referred(pain in same spinal nerve path)
What is neuropathic pain? quality? Give some examples of neuropathic pain (4).
Abnormal process of pain msg, most difficult to assess, injures PNS/CNS. -Burning, shooting, tingling. - Mono/polyneuropathies(damaged periphery nerves), Deafferentation(loss of afferent input from dmged periphery) Sympathetically maintained pain(SNS stim from periphery dmg) Central pain(lesions or dysfunction of CNS
What developmental considerations influence pain assessment?QUESTT
Infants(can't verbalize, have to use phys & beh) Children(QUESTT), Older adults(fxnal level & quality of life good indicators of effects of pain) Question child, use pn rate scale, eval beh/phys, secure pt involvement, take cause of pain in account, take action and eval.
What cultural variations affect pain assessment? RESPECT?
-culture influences psychological and behavioral responses -Realize own heritage/pt's Examine pt in cultural context Select easy q's Pace q's Encourage meaning of health/ill Check for understanding Touch w/in boundaries
Mary Kane has DJD and will be getting hip replaced. What hx q's would you ask prior to surgery to help manage post op pain? Would she exp acute + chronic pain? Which pain scale? What physio and beh indicators would indicate post op pain? Often reassess?
-What do u do to manage pain, do u use alternative means to control pain, which meds? -Chronic DJD, Acute post op - 0-10 - pt verbalizes cause, guards site, limited move, increase VS -pain assess q hr
What can the health history tell you about the patient's pain? (6)
Biographical Data(culture, belief), Current health status (PQRSTU), Past health history(cause of pain,etc), Family history(genetics), ROS, and Psychosocial(effect on life)
Symptom P
Provocative/palliative factors- What brings it on? what were you doing when your first noticed it? What makes it better/worse?
Symptom Q
Quality/Quant - how does it look/feel sound = descriptors (numb,burn,stab,etc) How intense/ severe?
Symptom R
Region/Radiation - Exact location of symptom area and area of radiation
Symptom S
Severity - ID sypmtoms how bad at it's worst(1-10 scale), and any associated symptoms? getting better, worse, or same?
Symptom T
Timing -identify first noticed, duration, frequency (how often), how it has changed/progressed, acute or chronic, constant, intermittent or recurrent
Symptom U
Understanding cause of pain, what do you think it is?
OLDCARTS?
Onset, location, duration, character, aggravating/assoc, radiation/relieving, treatment/timing, severity
What are the subjective pain scales for adults? for children?
Numeric rating scale 1-10, Visual analogue scale 10cm line mark. -Wong baker FACES
How does pain affect the systems: Cardiac? Pulmonary? GI? Renal? MS? Endo? CNS? Immune?
-increased BP, cardiac O2 demand, CO - hypoventilation, hypoxia, decreased cough, atelectasis - N&V, ileus - Oliguria, urinary retent -spasm, joint stiff -increased adrenergic activ -fear, anxiety, fatigue -impaired cellular immunity, wound healing
What are some objective pain scales used for Infants? what age used? Older adults?
CRIES(Crying Required Increase O2, Increased VS, Expression, Sleepiness, -32wks to 20wks post term. -riley infant pain scale <36 mos. -Pain assessment in Advanced dementia scale
What are you objectively measuring in abdomen for pain? (3)
Contour/symmetry, guarding, organ size
What are you measuring objectively in the musculoskeletal system? (7)
Joint size/countour/circum, ROM Muscle/skin color, swelling, masses, deformities, sensation changes.
What is being measured objectively in Neuro/Behavior? (3)
-nonverbal cues, acute pain behavior, chronic pain behavior
While examining a broken arm of a 4-year old boy, select the appropriate assessment tool to evaluate his pain status
A)0-10 numeric rating scale
B)Wong-Baker scale
C)Simple descriptor scale
D)0-5 numeric rating scale
B
The most reliable indicator of pain in the adult is:
a)Degree of physical functioning
b)Nonverbal behaviors
c)MRI findings
d)Patient’s self report
D