Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
178 Cards in this Set
- Front
- Back
|
What is the goal of nursing process
|
To identify a client's health status and actual or potential healthcare problems or needs, to establish plans to meet the individual needs, and to deliver specific nursing interventions to met those needs
|
|
|
WHAT ARE THE 5 PHASES OF THE NSG PROCESS
|
ADPIE ASSESSMENT DIAGNOSIS
PLANNING IMPLEMENTATION EVALUATION |
|
|
ASSESSMENT
|
COLLECT DATA
ORGANIZE DATA |
|
|
DIAGNOSIS
|
ANALYZE DATA
IDENTIFY NURSING DIAGNOSES AND COLLABORATIVE PROBLEMS |
|
|
PLANNING
|
PRIORITIZE PROBLEMS
IDENTIFY MEASURABLE GOALS (OUTCOMES) SELECT NURSING INTERVENTIONS DOCUMENT PLAN OF CARE |
|
|
IMPLEMENTATION
|
CARRY OUT THE NURSING PLAN
DOCUMENT THE NURSING CARE AND PATIENT RESPONSE |
|
|
EVALUATION
|
MONITOR PT OUTCOMES
RESOLVE CONTINUE REVISE THE CURRENT PLAN OF CARE |
|
|
THE NURSING PROCESS PROVIDES WHAT FOR THE NURSE
|
a systematic problem solving method used by nurses in providing nursing care.
|
|
|
"Practice of nursing" is defined as
|
diagnosing and treating human responses to actual or potential health problems through such services as identification thereof, health counseling and providing care supportive to or restorative of life and well-being.
|
|
|
What are the Characteristics of the Nursing process
|
Cyclic and dynamic nature, client centeredness, focus on problem solving and decision making, interpersonal and collaborative style, universal applicability and use of critical thinking
|
|
|
Care plans are
|
patient-centered-plan of care individualized for each person where pt is encouraged to actively participate.
|
|
|
Goals
|
irected-effort between the patient and nursing team to achieve desired outcomes-short and long term goals
|
|
|
ASSESSING is
|
the systematic and continuous collection, organization, validation and documentation of data and is carried out through all phases of the Nursing process
|
|
|
What are the 4 types of assessments?
|
Initial assessments
Problem focused assessments Emergency assessments Time-lapsed reassessments |
|
|
What do nsg assessments focus on
|
A clients response to a health problem
|
|
|
What is the purpose of assessment
|
To establish a database about the clients response to a health concern or illness and their ability to manage healthcare needs
|
|
|
What information does a database include
|
A nursing Health Hx. And nurses physical assessment along with the MD's Hx and Physical assessment of the Patient, results of all labs and Dx tests, and materials contributed by other health care personnel
|
|
|
A nursing assessment should include what
|
The client's perceived needs health problems, related experience, health practices, values and lifestyles. And the data collected should be relevant to a particular health problem to be most useful.
|
|
|
According to JCAHO an initial assessment and physical must be preformed and documented within what time frame?
|
Within 24 hours of being admitted as an inpatient
|
|
|
Emotional health
|
mental health state, coping styles etc
|
|
|
Social health
|
accommodation, finances, relationships, genogram employment status, ethnic back ground, support networks etc
|
|
|
Physical health
|
general health, illnesses, previous history, appetite, weight, sleep pattern, diurinal variations, alcohol, tobacco, street drugs; list any prescribed medication with comments on effectiveness)
|
|
|
Intellectual health
|
cognitive functioning, hallucinations, delusions, concentration, interests, hobbies etc
|
|
|
Subjective data
|
information that only the client feels and can describe (Symptoms)
|
|
|
Objective data
|
observable and measurable facts (Signs)
|
|
|
PRIMARY SOURCE OF DATA
|
Client
|
|
|
WHAT ARE THE 2NDARY SOURCES OF DATA
|
Client's family, records
|
|
|
During which phase of the nursing process is the care plan revised as needed
|
Evaluation
|
|
|
Signs &Symptoms of anxiety
|
*restlessness or feeling keyed up or on edge
* being easily fatigued * difficulty concentrating or mind going blank * irritability * muscle tension * sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep |
|
|
Maslow's hierarchy of needs
|
physiological
safety love/belonging esteem self-actualization |
|
|
What does a Nursing Dx do
|
It facilitates comprehensive nursing care by identifying the health problem and validating the contributing factor
|
|
|
What are the 3 Data collecting Methods
|
Observing, interviewing and examination
|
|
|
What are the 2 psychological problems clients on isolation precautions face
|
Sensory deprivation
Feeling of inferiority-client's perception of the infection itself or the required precautions-idea of being soiled, contaminated, or dirty given a feeling to the client that they are at fault, etc |
|
|
sensory depravation
|
environment lacks normal stimuli for the client & communication with others
|
|
|
What are the s/s of sensory deprivation
|
Boredom,INACTIVITY, Slowness of THOUGHT, Daydreaming, Increased sleeping, Thought disorganization, Anxiety, Hallucinations, Panic
|
|
|
Medical asepsis does what
|
Limits the number, growth, & transmission of microorganisms
|
|
|
Surgical aseptic practices do what
|
keep an area or objects free of all microorganisms
|
|
|
What's the 1st line of defense the body has against infection
|
What's the 1st line of defense the body has against infection
|
|
|
Why don't elders need to shower daily
|
Because aging changes their skin making it less protective The changes include skin is more fragile their skin has less oil and moisture and decreased elasticity. And showering using soap dries out the skin even more
|
|
|
s/s of gingivitis
|
bleeding, receding gum lines, formation of pockets between the teeth & gums
|
|
|
Define stomatitis
|
inflammation of the oral mucosa
|
|
|
.Give example of med that affects the skin
|
corticosteroids=thinning of the skin, & allow it to be much more readily harmed.
|
|
|
Define pressure ulcers
|
re due to localized ischemia, a deficiency in the blood supply to the tissue
|
|
|
Specifically what is need in the diet to prevent pressure ulcers
|
A diet rich in protein, carbs, lipids, Vitamins A&C and Iron, Zinc and Copper and at least 2,500 ml's fluid if not contraindicated
|
|
|
How can a decreased mental status lead to skin breakdown
|
reduced level of awareness, unconscious or heavily sedated-unable to recognize & respond to pain associated with prolonged pressure
|
|
|
hat is the purpose of a scab & the reason we teach children not to pull them off their cuts
|
because it is essential to healing & acts as a wound sealer
|
|
|
What are the 3 main types of drainage
|
1. Serous, 2. Purulent, 3. Sanguineous (hemorrhagic)
|
|
|
what does serous drainage come from and what does it look like
|
consist mainly of serous (the clear portion of the blood) it comes from blood & the serous membranes of the body
|
|
|
How do we clean wounds
|
Using the RYB color code
|
|
|
Using the RYB color code
R= |
Red wound and are cleansed with gentle cleansing with an approve cleanser
|
|
|
Using the RYB color code
Y= |
Yellow wounds and are cleansed to remove nonviable tissue can be cleansed with damp dressings, irrigation, absorbent dressings, nonadherant hydrogel dressings
|
|
|
Using the RYB color code
|
Black wounds and need to be cleaned by debridement
|
|
|
What is serosanguinenous exudates and is common for which clients
|
(consisting of clear & bloody tinged drainage)commonly seen in surgical incisions
|
|
|
What are the factors inhibiting wound healing in older adult
|
1.vascular changes 2. collagen tissue is less flexible 3. scar tissue is less elastic 4. nutritional deficiencies decreasing number of RBCs &leukocytes 5. changes in the immune system reducing formation of antibodies & monocytes 6. diabetes or cardiovascular disease 7. cell renewal is slower
|
|
|
How do diabetes and cardiovascular diseases inhibit wound healing
|
increases the risk of delayed healing due to impaired O2 delivery to these tissues
|
|
|
Why are obese clients at risk for wound infection and slower healing of wounds
|
Because adipose tissue usually has a minimal blood supply
|
|
|
What 3 types of drugs can interfere with wound healing
|
Anti-inflammatory/ antineoplastic agents/antibiotics-MOTRIN/ASPIRIN
|
|
|
What anti-inflammatory drugs interfere with healing
|
aspirin & steroids
|
|
|
What are the 3 guidelines for care of an untreated wound
|
control severe bleeding with direct pressure & elevate extremity prevent infection by cleansing, flushing, applying dressing without removing saturated dressings control swelling & pain by applying ice to area
|
|
|
What are the major goals for clients at risk for impaired skin integrity
|
to maintain skin integrity & to avoid potential associated risks. & they need to demo (self care abilities for mobility, wound care
|
|
|
When planning for home care it is the nurses' responsibility & is accountable to teach what
|
wound preventive & care measures
|
|
|
What are 3 ways nurses can teach clients optimal wound healing conditions
|
assess client's current level of knowledge 2. providing nutrition 3. maintaining skin hygiene
|
|
|
For wound healing fluid intake should be
|
2500cc if not contraindicated
|
|
|
2 main aspects to control wound infections
|
change dressing daily & prn to keep dressing dry & clean, inspect wound daily, report any s/s of infection
|
|
|
what interventions can be done to assist with nutrition for wound healing?
|
Instruct about foods high in PRO, vitamin C, encourage adequate Fluid intake
|
|
|
Any at risk for skin breakdown client should be repositioned how often
|
15 or 30 minutes
|
|
|
What are wet to damp gauze dressings used for & on what stage wounds
|
used to pack wounds that requires debridement-stage IV
|
|
|
If a microorganism produces no clinical sign of infection it is called
|
Asymptomatic or subclinical
|
|
|
Define communicable disease
|
If the infectious agent can be transmitted to an individual by direct or indirect contact, through a vector or vehicle, or as an airborne infection
|
|
|
And why do clients get nosocomial blood stream infections
|
Inadequate hand washing and or Improper intravenous fluid, tubing, and site care techniques
|
|
|
Define comforting
|
A group of Nursing interventions based on the clients cues of distress with a goal of achieving client comfort such as touch and listening
|
|
|
How should the nurse communicate with the adolescent?
|
Take time to build rapport with the adolescent, and use active listening skills, project a nonjudgmental attitude and non-reactive behaviors, even when adolescent says disturbing remarks
|
|
|
What environmental factors can effect communication
|
Temperature extremes, excessive noise, & a poorly ventilated environment can all interfere with a client's communication. Lack of privacy may also interfere. Environmental distraction can impair & distort communication.
|
|
|
What are the common responses by the nurse to convey attentive listening to the client
|
Nodding head, saying ah huh, or I see what you are saying
|
|
|
What are the 4 phases of the helping relationship
|
1. pre-interaction
2. introductory 3. working (maintaining 4. termination |
|
|
What's the pre-interaction phase for
|
It is very important because it sets the tone for the rest of the relationship
|
|
|
What are self help groups
|
a small, voluntary organizations composed of individuals who share a similar health, social, or daily living problem
|
|
|
What are therapy groups
|
Work towards self-understanding, more satisfactory ways of relating or handling stress, & challenging patterns of behavior toward health
|
|
|
When assessing verbal communication of a client the nurse needs to focus on what 3 areas
|
Language deficits-,Sensory deficits & Cognitive impairments
|
|
|
For the clients with coping problems or psychiatric problems impaired verbal communication is not appropriate...what other dx labels are used
|
Anxiety, Powerlessness, Situational Low Self Esteem, Social Isolation, Impaired Social Interaction
|
|
|
What are the 3 main theories of learning
|
a. Behaviorism b. Humanism. c.Cognitivism
|
|
|
Nonjudgmental support is
|
People learn best when they believe they are accepted and will not be judged
|
|
|
Emotions affect learning-
|
a. fear, b. anger c. depression can impede learning
|
|
|
How do culture aspects affect learning
|
Cultural barriers to learning such as language or values
|
|
|
How does one's psychomotor ability affect learning?
|
Muscle strength, Motor coordination, Energy level and sensory activity can affect ones ability to learn
|
|
|
Acute illness is a barrier to learning because:
|
Clients requires all resources and energy to cope with illness
|
|
|
Pain is a barrier to learning because
|
Decreases ability to concentrate
|
|
|
What barriers to learning do elders have
|
Vision, hearing and motor control can be impaired in elders
|
|
|
A comprehensive assessment of learning needs comes from what sources of data
|
Incorporated data from the nursing history and physical assessment
|
|
|
What are the special considerations for teaching elders
|
Consider sensory, motor deficits and adapt the teaching plan
|
|
|
How does the physical exam provide clues to learning need of the client?
|
Mental/Nutritional status, Energy level, Visual/Hearing ability, Muscle coordination
|
|
|
What is the most common method nurses use to teach
|
one on one discussion
|
|
|
Following the evaluation of the care plan & goal the nurse may need to do what
|
modify or repeat the teaching plan if the objectives have not been met or met partially.
|
|
|
When evaluating teaching who should evaluate the learning experience
|
Nurse and the Client
|
|
|
Why is documentation of the teaching process important
|
It provides a legal record that teaching process took place and communicates the teaching to other health professionals. If not documented legally it did not occur
|
|
|
What are the 3 main organisms of nosocomial pneumonia infections
|
Staphylococcus aureus, pseudomonas aeruginosa, and Enterobacter species
|
|
|
how do clients get nosocomial pneumonia infections
|
Inadequate hand washing and improper suctioning improper sterile procedures
|
|
|
What is the most important thing the nurse can do to prevent nosocomial infections
|
Wash hands before and after every thing you do
|
|
|
How can a Nosocomial infection negatively affect a client
|
extends hospitalization, causes disability & discomfort, loss from work and possible loss of life
|
|
|
Common sources/reservoirs are:
|
other humans, the client themselves, plants animals, and the general environment including food, water & feces
|
|
|
What is the portal of exit for respiratory tract infections
|
Mouth or nose through sneezing coughing or talking
|
|
|
After a microbe leaves its host, it needs a mode of transmission to get to the next person. What are the 3 main methods of transmission?
|
Direct, Indirect, & Airborne transmission
|
|
|
What is direct transmission
|
Is immediate and direct transfer of microorganisms from person to person by touching, kissing biting, or sexual intercourse
|
|
|
Droplet can also be a direct means of transmission if
|
Only the source and the host are within 3 feet of each other
|
|
|
What's a susceptible host
|
Any person who is at risk for infection
|
|
|
What are the 5 sign of inflammation-
|
Pain, swelling, redness, heat, and impaired function of the part,
|
|
|
Rubor=
|
redness
|
|
|
Tumor is
|
abnormal overgrowth of cells
|
|
|
Calor=
|
cardinal signs of inflammation
|
|
|
Dolor=
|
pain
|
|
|
What are the 3 stages of inflammation-
|
1st stage: vascular and cellular response 2nd stage: exudates production 3rd stage: reparative phase
|
|
|
Explain the 1st stage of inflammation
|
Constriction of the blood vessels, dilation of small blood vessels, more blood flow to the injured area, leukocytes to interstitial spaces, edema, and pain is caused by pressure of accumulating fluid
|
|
|
Explain the 2nd stage of inflammation
|
-Exudates are produced, fibrinogen and thromboblastin and platelets wall off the area to prevent the spread of injurious agents, injurious agent is overcome and the exudates is cleared away by lymphatic drainage
|
|
|
Explain the 3rd stage of inflammation
|
Repair of injured tissues by regeneration or replacement with fibrous tissue, fibrous scar tissue proliferates, damaged tissues are replaced with connective tissue elements, tissue shrinks and collagen fibers contract causing a cicatrix or scar
|
|
|
What are the factors that increase susceptibility to infection?
|
Age, heredity, level of stress, nutritional status, current medical therapy, and preexisting disease processes
|
|
|
What meds increase the susceptibility to infection
|
Anti-inflammatory, antineoplastic, and antibiotics
|
|
|
Remember many nosocomial infections can be prevented by
|
Using proper hand washing techniques environmental controls, sterile techniques when warranted and identification and management of clients at risk for infections
|
|
|
What is the most important step in interpreting nonverbal communication
|
Validate your perception with the person involved
|
|
|
Territory is best defined as:
|
An emotional perception of special relationship
|
|
|
Seeing and feeling an experience as a patient does is referred to as
|
Empathy
|
|
|
The nurse assists the patient to explore thoughts, feelings, and actions during which phase of the nurse-patient relationship
|
Working phase
|
|
|
The nurse may observe resistive and testing behavior in a patient during which phase of nurse-patient relationship
|
Introductory phase
|
|
|
The nurse seeks to clarify the patient's problem during which phase of the relationship
|
Introductory phase
|
|
|
In which situation would effective communication be most apt to occur
|
Focusing on the needs of the patient
|
|
|
When a nurse communicates no judgements about a patient's actions, thoughts, or feelings, she is demonstrating
|
Acceptance
|
|
|
A newly diagnosed diabetic patient needs to be taught self-administration of insulin. The best time to teach this patient is
|
2 days after the patient is informed of her diagnosis when her husband is visiting
|
|
|
Tell me more about this pain you are experiencing" is an example of the communication technique called:
|
Exploring
|
|
|
"You say that your last episode of indigestion was last Tuesday & you've been avoiding spicy foods..." is an example of the communication technique called:
|
Restating
|
|
|
A patient who is admitted to the hospital for the first time conveys his fears and concerns to the nurse. The nurse's response is, "You have chosen the best hospital, so don't worry, everything will be fine. " This response is an example of
|
False reassurance
|
|
|
A 4 y/o child needs preoperative teaching. The nurse should plan to include which of the following strategies in the teaching plan
|
Role play with dolls
|
|
|
The nurse plans to assist an adolescent patient to deal with her anger. Which action should the nurse take initially
|
Accept the patient's feelings
|
|
|
Which of the following best describes a therapeutic environment?
|
It is a climate that helps a person to maintain a feeling of worth & allows the greatest likelihood of success for care.
|
|
|
A 20 y/o male patient laughs while discussing his recent BKA but has tears in his eyes. The nurse would accurately recognize the he is conveying of the following
|
Incongruence- Lacking in harmony; incompatible: a joke that was incongruous with polite conversation
|
|
|
he greatest inhibitor of effective communication is:
|
Failing to listen to the patient
|
|
|
The nurse asks a patient questions to obtain information out of curiosity without intending to assist the patient. This is an example of:
|
Probing
|
|
|
Which age group should the nurse plan to conduct a teaching session with using a client contract
|
Adolescents
|
|
|
Feelings of loss are most likely experienced by the nurse & the patient during which phase of the relationship?
|
Termination phase
|
|
|
The nurse, when caring for a patient from a different culture who does not speak the nurse's language, should plan:
|
Observe the patient's response to touch & only use touch when it is known to be acceptable to the patien
|
|
|
When caring for young children, it is important to do which of the following during the 1st interaction?
|
Speak in a soft tone of voice
|
|
|
Which approach should be used by the nurse to encourage the development of a therapeutic nurse-patient relationship
|
Listen in an active way
|
|
|
A patient's response to the nurse's questions is shrugging his shoulders. Which action would best facilitate communication?
|
Attempt to validate the meaning of this nonverbal message
|
|
|
Which action should the nurse include when preparing a 12 y/o child for a procedure?
|
Encourage active participation on the part of the child
|
|
|
onverbal behavior is probably the most accurate indicator of a person's true thoughts & feelings because nonverbal messages are:
|
Unconsciously expressed
|
|
|
WHAT IS THE LEADING CAUSE OF DEATH FOR YOUNG ADULTS
|
Motor vehicle accidents
|
|
|
WHAT IS THE MAJOR CONCERN OF THE OLDER ADULT R/T SAFETY
|
Accident prevention
|
|
|
WHAT 2 DISEASES ASSO. WITH THE OLDER ADULT PUT THEM AT RISK FOR INJURY R/T WANDERING
|
Organic brain syndromes
Alzheimer disease |
|
|
WHAT MEDS FREQUENTLY TAKEN BY older adults PUT THEM AT A GREATER RISK FOR INJURY AND WHY
|
Analgesics
Sedatives o Become lethargic or confused |
|
|
WHAT IS THE MAJOR CAUSE OF HOSPITAL ADMISSIONS FOR THE OLDER ADULT
|
Falls
|
|
|
WHAT ARE THE SPECIFICS TO USING RESTRAINTS FOR BEHAVOR MANAGEMENT
|
Nurse apply restraints but the physician or other licensed independent practitioner must see the client within 1 hour for evaluation
§ Valid for 4 hours only § Orders should be renew daily |
|
|
TYPE OF RESTRAINTS USED FOR SEDATED OR CONFUSED CLIENTS
|
Vests
§ Sleeveless jackets |
|
|
TYPE OF RESTRAINT USED IN TRANSFERS VIA STRETCHER OR W/C
|
Belt and/or safety strap
|
|
|
WHAT DO "y" STRAPS DO
|
Prevent a client from slumping forward
|
|
|
WHAT ARE HAND MITTS USED FOR
|
To use in the prevention of confused clients from using their hands or fingers to scratch and injure themselves
|
|
|
WHAT ARE THE 2 PURPOSES OF APPLY A RESTRAIN
|
Enable the client to receive treatment
Allow the treatment to proceed without client interference |
|
|
WHAT 2 KINDS OF KNOTS ARE USED TO TIE A RESTRAINT
|
HALF KNOT his knot does not tighten or slip when attached end is pulled but unties easily
HALF BOW KNOT |
|
|
RESTRAINTS ARE TIED TO WHAT PART OF THE BED
|
Movable part
|
|
|
IMPORTANT INTERVENTION TO PREVENT BREAKDOWN R/T THE USE OF WRIST OR ANKLE RESTRAINTS
|
Pad bony areas to prevent skin breakdown
|
|
|
Psychological coping mechanism
|
uses defense mechanisms to mentally accept new situations. these defense mechanisms may protect individuals for a limitied period of time but can block change and growth. For health resoution of stress, these defenses need replaced by effective coping strategies.
|
|
|
Repression
|
preventing stressful thoughts and feelings from entering the conscious
|
|
|
Reaction formation
|
expression of a feeling that is the opposite of one's real feeling
|
|
|
Suppression
|
an attempt to keep unpleasant material out of consciousness
|
|
|
Sublimination
|
displacement of energy associated with more aggressive drives into socially acceptable activities
|
|
|
Denial
|
avoiding the threat of a stressor by reinterpreting the event as something less threatening
|
|
|
Displacement
|
the transferring or discharging of emotional reactions from one object or person to another object or person
|
|
|
Regression
|
reverting to less mature behavior
|
|
|
Repression
|
an unconcious mechanism by which threatiening thoughts are kept from becoming conscious
|
|
|
Rationalization
|
intellectual explanation or justification of ideas, feelings, or behavior
|
|
|
Projection
|
attribution of one's own thoughts, feelings or impulses of others
|
|
|
Displacement
|
directing anger and aggression toward innocent people
|
|
|
Undoing
|
an action or words designed to cancel some disapproved thoughts, impulses, or acts in which the person relieves guilt by making reparation
|
|
|
Coping with Stress
|
coping strategy is an innate or acquired way of responding to a changing enviorment or specific problem or situtation
|
|
|
Emotion-focused coping
|
includes thoughts and actions that relieve emotional distress. Doesn't improve the situation but the person feels better
|
|
|
Problem- focused coping-
|
refers to efforts to improve a situation by making changes or taking some action. (Neutralizes stressor)
|
|
|
Anxiety-
|
a state of mental uneasiness, apprehension, dread, or foreboding, or a feeling of helplessness related to an impending or anticipated unidentified threat to self or significant relationships. It is a subjective response that occurs when a person experiences a real or perceived threat to well being
|
|
|
Nursing Process
|
is a systamatic process that is rational, continuous, cyclical and dynamic, goal-oriented, client centered and interpersonal, collaborative and universally applicable.
|
|
|
Health, Wellness, and Illness-
WHO defines health as |
a state of complete physical, mental, and social well being, not merely the absence of disease or infirmity
|
|
|
primary care agencies are
|
public health, physicians office, public health,ambulatory care centers: health promotion, preventative care, health education, enviromental protection early detection and treatment
|
|
|
secondary care
|
the segment of the health care delivery system that is dedicated to the diagnosis and treatment of illness. Hospitals and physicians office used to be the major agencies offering these services, now clinics in community based areas asssist in this area.
|
