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178 Cards in this Set

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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.