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42 Cards in this Set

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date and sign the plan
essential for evaluation, review, and future planning. nse's signature demonstrates accountability
catagory headings
"nursing dx","goals or desired outcomes", nursing interventions", "evaluation".
Use standardized medical or English symbols rather than complete sentences
for example Turn and repositon q2h instead of turn and reposition every two hours.
Be specific
shifts can be 8 hours or 12 hours. witing orderes needs to have specific times and not q shift
refer to procedure book or other sources
for steps of care such as trach care, write see procedure book instead of writting out all steps
tailor plan to unique characteristics of the client by ensuring client choices such as time preferences, and methods are included
reinforces clients individuality and sence of control
ensure careplan incorporate preventative and health maintenence aspects as well as restorative
for example, active range of motion to affected limbs q2h. prevents contractures and maintains muscle strength
ensure care plan has interventions for ongoing assessment
for example, inspect incision q8h
include collaborative and coordination activies
for example, PT OT ST or nutritionist consult
include plans for client discharge and home care needs
often necessary to consult and make arrangements with community health nurse, social worker,and specific agencies that supplythat supply client info and eqipment. add teaching and discharge planning as an addendaif are lengthy and complex.
The Planning Process- processs of developing client care plans
1 set priorities
2 establish desired goals and patient outcomes
3 selecting nursing interventions
4 writing nsg orders
components of a goal
subject, verb, conditions or modifiers,criterion for desired performance
components of a nsg order
date, action verb, content area, time element, signature
cognitive skills
intellectual skills
interpersonal skills
all activities, verbal and nonverbal, people use when interacting directly with one another.
technical skills
hands on skills
evaluation is...
continuous
evaluation statements
consists of conclusion and supporting data. statement that goal was met, partially met or not met.
inflammation and local infection
pain, swelling, redness, heat and impaired function
systemic infection
fever, elevated pulse,elevated respirations, malaise, loss of energy, anorexia, n&v, enlarged and/or tender lymph nodes. leucocytes > 11,000, elevated ESR.
wound healing
absence of bleeding or clots binding the edges, inflammation at wound edges at first then decrese in inflammation as clot deminishes, scar formation, diminished scar over peiod of months to years.
The Helping Relationship
interpersonal relationships or interpersonal relationships
Preinteraction phase
similar to planning phase prior to an interview. nurse has some limited information
introductory phase
orientation phase or prehelping. sets tone for the rest of the relationship. client may display some resistive behaviors
working phase
nse helps client explore thoughts, feelings, actions and helps the client plan a programor action tomeet preestablished goals
skin integrity
normal is prescence of normal skin and skin layers uniterrupted by wounds. skin integrity is first line of defense against infection.
parts of med orders.
clients full name, date and time order was written, name of drug to be administered,dosage of med route of admin, signature of Dr or nurse making drug request.
sterile field
micro-organism free area
all objects in a sterile field must be sterile
all articles are sterile with the field,always check package for intactness, check expiration date, storage areas needs to be clean, dry, off the floor and away from sinks.
sterile objects become unsterile when touched by unsterile objects
handle sterile objects that will touch open wounds or enter body cavities only with sterile forcepts or sterile gloves
sterile items that are out of site or below the waist level of the nurse are considered unsterile
once left unattended field in unsterile, do not turn back to sterile field, only front part of sterile gown from waist to shoulders and 2in above the elbowsto the cuff of the sleeve is condiered sterile, keep sterile gloves above waist and in sight and only touch sterile things, once a sterile field becomes unsterile, it must be set up again before proceeding.
sterile objects can become unsterile by prolonged exposure to airborne micro-organisms
moving air can carry dust particles and microorganisms, keep doors closed and traffic to a minimum, keep areas clean by damp cleaning with a germicide, keep hair clean and contained to keep it from falling into a sterile field, wear surical caps in OR, no sneezing or coughing over sterile field, nse with URI needs to refrain from doing procedures, keep talking to a minimum over a sterile field, do not reach over a sterile field
fluids flow in the direction of gravity
always hold forceps with the tips below the handles, after surgical hand washing, hold hands higher than the elbows.
moisture that passes through a sterile field draws microorganisms from unsterile surfaces to sterile surfaces by capillary action
sterile moisture proof barriers are used beneath sterile objects, keep sterile covers on sterile containers dry, replace sterile field when they become moist
the edges of a sterile field are considered unsterile
a 1 inch margin at each edge of an open drape is considered unsterile because the edges are in contact with unsterile surfaces
Skin is unsterile and cannot be sterilized
use sterile gloves or sterile forceps to handle sterile items, wash hands to reduce number of microrganisms
Conscientous, alertness, and honesty are essential qualities in maintaining surgical asepsis
when an object becomes unsterile it does not necessarily change in appearance, person who sees an object become unsterile must correct or report situation do not set up a sterile field ahead of time or future use
application of heat to a wound
increases capillary permeability, increases cellualr metabolim increases inflammation sedative effect, vasodilation. softens exudateincreases blood flow to specific area bringing oxygen, nutrients, antibodies an leukocytes.
drug half life
time required for the elimination process to reduce the concentration of a drug to one- half what ot was at initial administration
use of fire extinguishers
PASS- Pull pin, Aim, Squeeze, Sweep
fluid volume deficit
occurs when the body loses both water and electrolytes.goals include maintain or restore fluis balance, maintain or restore normal balance of electrolytes in the intracellular and extracellular compartments, maintain or restore pulmonary ventilation and oxygenation, prevent associated resks ( tissue breakdown, decreased cardiac output, confusion, other neurolgic signs).
sensory overload
occurs when a person is unable to process or manage the amount or intensity of sensory stimuli. imterventions can include minimizing unnecessary distraction, control pain, introduce self by name and address client by name, provide orientation cues, provide a private room, limit visitors, plan care to allow for uninterrupted periods of sleep and rest speak in a low tone and in a unhurried mannor, provide new info gradually, describe procedure and tests before hand. reduce noxious odors, take time to duscuss clients problems, assist client with stress reducing techniques