Exam 1 Flashcards
Systematic way of planning and providing care; involve decision making process, judgement and problem solving
The Nursing Process
ADPIE
Assessment Diagnosis Planning Implementation Evaluation
Level of nursing that is task oriented, rule oriented, inflexible.
Slow, methodical
Novice nurse
Level of nursing that is intuition oriented, uses patterns
Fast, fluid.
Expert nurse
Part of the nursing process that is systemic, continuously gathering, organizing, and validating date
Assessment
TJC requires H&P to be completed with __ hours of admission
24
Types of assessment date
Objective
Subjective
Types of assessment sources
pt
pt significant other
pt records
HCPs
Methods of collecting assessment data
Observation
Interview
Examination
The 4 types of nursing diagnosis
actual problem (present issue) potential problem (risk for) health promotion (ready to learn) syndrome (several similar problems)
part of the nursing process that uses assessment data and nursing diagnosis to formulate a goal and design interventions to meet the goal
Planning
any treatment based upon clinical judgement and knowledge that a nurse performs to enhance pt/client outcomes
nursing intervention
independent interventions
license to implement based on our knowledge skills
emotional support, basic care
dependent interventions
require an order from a provider
medication administration
collaborative interventions
works with other members of healthcare team to carry out
things to keep in mind when choosing a nursing intervention
safe and appropriate achievable congruent with client goals congruent with other therapies based on nursing knowledge within scope of practice
Who is responsible for implementing interventions?
RN
What must be done after every intervention?
Reassess
Key points when implementing interventions
assess before, after determine need for assistance base on nursing knowledge know what you're doing adapt to pt needs be safe teach, support, comfort holistic respect dignity encourage pt participation
What are the 2 modes of communication
verbal
nonverbal
erect posture, purposeful steady gait shows ___
confidence
slouched posture, slow shuffling gait shows ___
depression, discomfort
tense posture, rapid determined gait shows ___
anxiety
avert eyes shows ___
embarrassment
intimate spacing
0-1.5 feet
touching, assessing
we often need to violate the pts personal space for assessments
person spacing
1.5-4 feet
more comfortable for conversation, often informal
people tense when someone enters their personal space
social spacing
4-12 feet
formal communication
making rounds
public spacing
more than 12 feet
lose individuality
what are the phases of helping (healthy??) relationship
preinteraction
introduction
working phase
resolution
preinteraction phase
gather information, plan
introductory phase
sets tone, develops trust
sets pt at ease
working phase
exploring and understanding
working
communication with older adults
assistive devices communication aids decrease distractions speak sport, simple sentences face the pt allow time to respond include family in convo
safety alert: faxing
let receiver know its coming
cover sheet
correct number
remove pt identifiers if able
purpose of EHR
interdisciplinary communication data for planning care audits research education reimbursement legal/evidence analysis/quality improvement
types of nursing documentation
narrative SOAP ADPIE focus charting charting by exception (DBE)
narrative documentation
write it out
SOAP
subjective
objective
assessment
plan
focus charting
action, response
CBE
flow sheets and defined norms
sums up care and instructions
used when transferring to another facility or sending home
discharge summary
what should discharge instructions include
condition, procedures care of wounds/incisions/drains med list and education restrictions (driving, lifting) instructions (activity, exercise) appointments when to seek care (fever, pain)
charting guidelines
chart changes (show f/u) read prior nurse notes be timely (avoid late charting) objective, subjective factual correct errors chart teachings use pt "actual words" review sign eliminate blank spaces
latin verb meaning “to suffer”
patient
latin verb meaning “to lean”
client
Maslow Hierachy of Needs
physiologic safety and security sense of belonging and affection esteem and self-respect self-actualization
WHO defines ____ as a “state of complete physical, mental, and social well being an not merely the absence of disease and infirmity”
health
What are the 4 components of wellness
capacity of perform to the best of ones ability
ability to adjust and adapt to varying situations
reported feeling of well-being
feeling that “everything is together” and harmonious
this focuses on the potential for wellness and targets appropriate alterations in personal habits, lifestyle, and environment in ways that reduce risks and enhance health and well-being
health promotion
cognitive process that utilizes thinking that is purposeful, insightful, reflective, and goal directed in order to develop conclusions, solutions, and alternatives that are appropriate for the given situation
includes reasoning and judgement
critical thinking
___ ___ has been identified as an essential core competency for nurses
critical thinking
the examination of one’s own reasoning or thought process
involves reflective thinking as well as awareness of the nursing skill needed for pt-centered care
metacognition
critical components of clinical reasoning
communication and relationships
educational level
knowledge and ability to use critical thinking
familiarity with the environment and context of care
experience and exposure to a variety of situations
professionalism
justification of actions or interventions used to address pt problems and help pts move towards desired outcomes
explanation
process of determining whether outcomes have been met
evaluation
examining the care provided and adjusting the intervention as needed
self-regulation
decision making skills include:
systematic and comprehensive assessment
recognition of assumptions
inconsistencies and biases
verification of reliability and accuracy
identification of missing info
distinguishing relevant from irrelevant info
support of the evidence with facts and conclusions
priority setting with timely decision making
determination of pt-specific outcomes
reassessment of responses and outcomes
certain physiologic complications that nurses monitor to detect changes in the status or onset of complications
collaborative problems
when does the implementation phase of the nursing process end?
when the interventions have been completed
formal, systematic study of moral beliefs to understand, analyze, and evaluate matters of right and wrong
ethics
often used interchangeably with morality
includes specific values, characteristics, or actions whose outcomes are often examined through systematic ethical analysis
morality
often used interchangeably with ethics
when to obtain wound culture?
after wound care has been performed
care to be provided to NGT pts
oral care
assess nares
SQ locations
abdomen top of thighs upper buttock scapula back of arms
Deltoid can not receive more than __ mL.
Must use a __ inch needle
1 mL
1 inch needle
Needle size and mL amount for IM, besides deltoids
3mL
1.5 ich
what to draw back in syringe before placing in vial
air
ID angle
15 degree, almost parallel to arm
___ before ___ insulin
clear before cloudy
Can you shake NPH insulin (cloudy)?
No, roll between hands
___ for SQ, hold ___ for IM
pinch - SQ
taut - IM
Subjective data
information gathered from pt statements
pt feelings and perceptions
Objective data
information that can be observed by others
Primary source
obtained from the pt
