Nursing Process/kozier

Front 1

what is the goal of the nursing process

Back 1

The goals of the nursing process are to identify a client's actual or potential health care needs, to establish plans to meet the identified needs, and to deliver and evaluate specific nursing interventions to meet those needs.
NP is cyclic; cient centered, interpersonal and collaborative, universally applicable and focuses on problem solving and decision making.

Front 2

What are the parts of the nursing process?

Back 2

assessing, diagnosing, planning, implementing and evaluating.

Front 3

What does assessing involve?

Back 3

collecting
organizing
validating
recording data

Front 4

What is the part of diagnosing in the nursing process?

Back 4

diagnosing is the process of making a clinical judgement (nursing diagnosis) about a client's potential or actual health problems.

Front 5

What does planning involve?

Back 5

planning involves setting priorities, writing goals/desired outcomes and establishing a written plan for nursing interventions.

Front 6

What does planning involve?

Back 6

planning involves setting priorities, writing goals/desired outcomes, and establishing a written plan for nursing interventions.

Front 7

What does implementing involve?

Back 7

Implementing is carrying out the nursing interventions. It incorporates all the activities performed to promote health, prevent complications, treat present problems and facilitate the clients coping with chronic alterations in health status.

Front 8

What is the part of evaluating in the nursing process?

Back 8

evaluating is the process of comparing client responses to preselected outcomes to determine whether goals have been met. It includes review and modification of the care plan.

Front 9

What does assessment involve?

Back 9

active participation by the client and nurse in obtaining subjective and objective data about the clients health status.

Front 10

what is subjective data?

Back 10

aka or referred to as symptoms or covert data
REMEMBER subjective data
Subjective: apparent only to the person affected & can be described or verified only by that person.

Front 11

What kind of data is itching, pain and feelings of worry?

Back 11

Subjective data

Front 12

What is objective data?

Back 12

also referred to as signs or overt data are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt or smelled and they are obtained by observation or physical examination.

Front 13

What kind of data is discoloration of the skin?

Back 13

Objective data

Front 14

What kind of data is taking a blood pressure?

Back 14

Objective data

Front 15

If a famiy member, significant other, or health professionals give data (not based on fact) what is it?

Back 15

Subjective

Front 16

If a clients daughter states, "dad couldn't remember his address or phone numer today"(remember fact)

Back 16

Objective data

Front 17

Name the chain of infections?

Back 17

1. etiologic agent (microorganism)
2. Reservoir (source)
3. Portal of exit from reservoir
4. Method of transmission
5. Portal of entry to the susceptible host.
6. susceptible host

Front 18

what are the major sites for nosocomial infections?

Back 18

infections of respiratory & Urinary tract
bloodstream
wounds

Front 19

what factors contibute to nosociamial infection?

Back 19

imvasive procedures
medical therapies
the existence of a large number of susceptible persons
inappropriate use of antibiotics
INSUFFICIENT HAND WASHING

Front 20

What are the body's first line of defense against microorganisms?

Back 20

SKIN

Front 21

What is the etiology of Pressure Ulcers?

Back 21

Pressure ulcers are due to localized ishemia. ( a defeciency in the blood supply to the tissue.

Front 22

What is a partial thickness wound?

Back 22

Partial thickness is confiend to the skin, that is the dermis and epidermis; heal by regeneration.

Front 23

What is a full thickness wound?

Back 23

Involves the dermis
epidermis
subcutaneous tissue and possible muscle and bone
require connective tissue repair.

Front 24

There are four stage of pressure ulcers what is stage 1?

Back 24

stage 1: non blanchable erythemia signaling potential ulceration.

Front 25

What are characteristics of stage 2 pressure ulcer?

Back 25

partial thickness
blister
involves epidermis and POSSIBLE DERMIS

Front 26

What are characteristic of stage III?

Back 26

Stage 111 involves full thickness --- deep crater

Front 27

What are characteristics of stage IV

Back 27

Full-thickness with tissue necrosis or damage to muscle, bone or supporting structures.

Front 28

There are different types of wound healing what are they?

Back 28

Primary intention healing
Secondary intention healing

Front 29

What is primary intention healing?

Back 29

Primary -- occurs where the tissue surfaces have been approximated (closed) thre is mnimal or no tissue loss:

Front 30

Give some examples of Primary healing?

Back 30

closed surgical incision
tissue adhesive (liquid glue)

Front 31

What is an example of secondary healing?

Back 31

Secondary healing is extensive and involves considerable tissue loss in which tghe edges cannot or should not be approximated.
An example of secondary healing is PRESSURE ULCER.

Front 32

Name the three ways that secondary intention differs from primary?

Back 32

1. the repair time is longer
2. the scarring is greater
3. susceptibility to infection greater

Front 33

name the 3 phases of wound healing?

Back 33

1. inflamatory
2 proliferative
3 maturation or remodeling.

Front 34

When does inflammatory phase occur and what happens?

Back 34

occurs immediately after injury and lasts 3 to 6 days.
Two major processes occur:
1. hemostasis
2. phagocytosis

Front 35

when does proliferative phase occur?

Back 35

day 4 or 4 to about day 21post injury.

Front 36

When does maturation phase occur?

Back 36

Begins from about day 21 and extend 1 or 2 years post injury.

Front 37

what is serous exudate?

Back 37

serous membrane of the body it looks watery and has fe cells. An example of serous drainge is a blister.

Front 38

what is purulent exudate?

Back 38

Thicker PUS (process of pus formation is referred to as suppuration. Remember question with suppuration anser is purulent.

Front 39

what is sanguinious (hemorrhagic) exudate

Back 39

large amounts of rbc's this type of exudate is frequently seen in open wounds.

Front 40

what is serosanguineous drainage?

Back 40

clear with blood tinged sometimes seen in surgical incisions.

Front 41

What is purosanguinious discharge?

Back 41

Pus and blood -- new wound that is infected.

Front 42

What does bright sanguinious exudate indicate?

Back 42

Fresh bleeding

Front 43

What does dark sanguineous exudate denote?

Back 43

Older bleeding