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43 Cards in this Set

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what is the goal of the nursing process
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.
What are the parts of the nursing process?
assessing, diagnosing, planning, implementing and evaluating.
What does assessing involve?
collecting
organizing
validating
recording data
What is the part of diagnosing in the nursing process?
diagnosing is the process of making a clinical judgement (nursing diagnosis) about a client's potential or actual health problems.
What does planning involve?
planning involves setting priorities, writing goals/desired outcomes and establishing a written plan for nursing interventions.
What does planning involve?
planning involves setting priorities, writing goals/desired outcomes, and establishing a written plan for nursing interventions.
What does implementing involve?
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.
What is the part of evaluating in the nursing process?
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.
What does assessment involve?
active participation by the client and nurse in obtaining subjective and objective data about the clients health status.
what is subjective data?
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.
What kind of data is itching, pain and feelings of worry?
Subjective data
What is objective data?
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.
What kind of data is discoloration of the skin?
Objective data
What kind of data is taking a blood pressure?
Objective data
If a famiy member, significant other, or health professionals give data (not based on fact) what is it?
Subjective
If a clients daughter states, "dad couldn't remember his address or phone numer today"(remember fact)
Objective data
Name the chain of infections?
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
what are the major sites for nosocomial infections?
infections of respiratory & Urinary tract
bloodstream
wounds
what factors contibute to nosociamial infection?
imvasive procedures
medical therapies
the existence of a large number of susceptible persons
inappropriate use of antibiotics
INSUFFICIENT HAND WASHING
What are the body's first line of defense against microorganisms?
SKIN
What is the etiology of Pressure Ulcers?
Pressure ulcers are due to localized ishemia. ( a defeciency in the blood supply to the tissue.
What is a partial thickness wound?
Partial thickness is confiend to the skin, that is the dermis and epidermis; heal by regeneration.
What is a full thickness wound?
Involves the dermis
epidermis
subcutaneous tissue and possible muscle and bone
require connective tissue repair.
There are four stage of pressure ulcers what is stage 1?
stage 1: non blanchable erythemia signaling potential ulceration.
What are characteristics of stage 2 pressure ulcer?
partial thickness
blister
involves epidermis and POSSIBLE DERMIS
What are characteristic of stage III?
Stage 111 involves full thickness --- deep crater
What are characteristics of stage IV
Full-thickness with tissue necrosis or damage to muscle, bone or supporting structures.
There are different types of wound healing what are they?
Primary intention healing
Secondary intention healing
What is primary intention healing?
Primary -- occurs where the tissue surfaces have been approximated (closed) thre is mnimal or no tissue loss:
Give some examples of Primary healing?
closed surgical incision
tissue adhesive (liquid glue)
What is an example of secondary healing?
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.
Name the three ways that secondary intention differs from primary?
1. the repair time is longer
2. the scarring is greater
3. susceptibility to infection greater
name the 3 phases of wound healing?
1. inflamatory
2 proliferative
3 maturation or remodeling.
When does inflammatory phase occur and what happens?
occurs immediately after injury and lasts 3 to 6 days.
Two major processes occur:
1. hemostasis
2. phagocytosis
when does proliferative phase occur?
day 4 or 4 to about day 21post injury.
When does maturation phase occur?
Begins from about day 21 and extend 1 or 2 years post injury.
what is serous exudate?
serous membrane of the body it looks watery and has fe cells. An example of serous drainge is a blister.
what is purulent exudate?
Thicker PUS (process of pus formation is referred to as suppuration. Remember question with suppuration anser is purulent.
what is sanguinious (hemorrhagic) exudate
large amounts of rbc's this type of exudate is frequently seen in open wounds.
what is serosanguineous drainage?
clear with blood tinged sometimes seen in surgical incisions.
What is purosanguinious discharge?
Pus and blood -- new wound that is infected.
What does bright sanguinious exudate indicate?
Fresh bleeding
What does dark sanguineous exudate denote?
Older bleeding