Exam 1 Flashcards
the protection, promotion, and optimization of health and abilities; prevention of illness and injury; facilitation of healing; alleviation of suffering through the diagnosis and treatment of human response; and advocacy in the care of individuals, families, groups, communities, and populations.
Nursing
- To promote health
- Prevent illness
- Restore health
- Coping with death or disability
4 broad aims in nursing
Assessment
Diagnosis
Planning
Implementation
Evaluation
ADPIE
- preparing for data collection
- collecting data
- identifying cues and making inferences
- validating data
- clustering related data and identifying patterns
- reporting and recording data
Assessing
vitals, demographics, family/medication history
assessing
- initial comprehensive assessment
- focused assessment
- emergency assessment
- time-lapsed assessment
types of nursing assessments
- Performed shortly after admittance to hospital
- Performed to establish a complete database for problem identification and care planning
- Performed by the nurse to collect data on all aspects of patient’s health
initial comprehensive assessment
- May be performed during initial assessment or as routine ongoing data collection
- Performed to gather data about a specific problem already identified or to identify new or overlooked problems
- Performed by the nurse to collect data about the specific problem
focused assessment
- Performed when a physiologic or psychological crisis presents
- Performed to identify life-threatening problems
- Performed by the nurse to gather data about a life-threatening problem
- Ex. Acute respiratory distress, suicidal ideation, severed limb, epilepsy, stroke, MI, chest pain
emergency assessment
- To compare a patient’s current status to baseline data obtained earlier
- To reassess health status and make necessary revisions in care plan
- By the nurse to collect data about current health status of patient
time-lapsed assessment
Which one of the following assessments would be performed on a patient to gather data on previously diagnosed liver cancer?
focused assessment
patient, family/significant others, patient record, nursing and other healthcare literature
sources of patient data
- nursing observation
- patient interview
- physical assessment
methods of data collection
inspection, palpation, percussion, auscultation
physical assessment
- ABC
- Vital signs
- Level of consciousness
establishing assessment priorities
airway
breathing
circulation
ABC
blocked (choking or anaphylaxis) or patency
airway
wheezing, cough, or clear
breathing
bleeding, clotting
circulation
temp, pulse, BP, respiratory, pain rating and description
vital signs
- awake and alert
- lethargic
- stuporous
- comatose
level of consciousness
- fully awake; oriented to person, place, and time; responds to all stimuli, including verbal commands
- Awake: Eyes are open
- Alert: follows directions
- Oriented: know who you are, where you are, and why you are there
- A&O x 4: awake and oriented to person, place, time, and situation
awake and alert
appears drowsy or asleep most of the time but makes spontaneous movements; can be aroused by gentle shaking and saying patient’s name
lethargic
unconscious most of the time; has no spontaneous movement; must be shaken or shouted at to arouse; can make verbal responses, but these are less likely to be appropriate; responds to painful stimuli with purposeful movements
stuporous
ex. Sternal rubs is very painful and will wake them up and their purposeful movement is their reaction of pain
purposeful movement
cannot be aroused, even with use of painful stimuli; may have some reflex activity (such as gag reflex); if no reflexes present, is in a deep coma
comatose
- Information perceived only by the affected person
- symptoms
- ex. pain description, gender
subjective data
- Observable and measurable data seen, heard, or felt by someone other than the person experiencing them
- AKA signs
- Example: vital signs, BP, height, weight, breath sounds, biological gender
objective data
- One of the nurse’s primary ethical responsibilities is safeguarding the privacy of patients
- Nurses must be familiar with their institution’s policies on privacy and on the requirements of the Health Insurance Portability and Accountability Act (HIPPA)
- American Nurse Association and National Council of State Boards of Nursing united to provide guidelines on social media for nurses
privacy, confidentiality, and professionalism
True or false: a patient rates his pain as a “7” on a pain rating scale. This rating is considered to be objective data
False
- interpret and analyze patient data
- identify patient strengths and health problems
- formulate and validate nursing diagnosis
- develop a prioritized list of nursing diagnoses
- detect and refer signs and symptoms that may indicate a problem beyond the nurse’s experience
Diagnosis
- Individualizing patient care
- Defining domain of nursing to health care administrators, legislators, and providers
- Seeking funding for nursing and reimbursement for nursing services
benefit of nursing diagnoses
- Describes patient problems nurses can treat independently
- Ex. Deficient fluid volume
nursing diagnoses
- Describes problems for which the physician directs the primary treatment
- Ex. Dehydration
medical diagnoses
- problem-focused
- risk
- health promotion
types of nursing diagnoses
- Undesirable human response to a health condition/life process
- Ex: Imbalanced nutrition
problem-focused nursing diagnosis
- Vulnerability for developing an undesirable human response to health conditions/life processes
- Ex. Risk for infection
risk nursing diagnosis
- Motivation and desire to increase well-being and to actualize human health potential
- Ex: readiness for enhanced self-care
health promotion nursing diagnosis
- Phrase as patient problem of altered health state
- Patient problem must precede etiology linked by “related to” (R/T)
- Defining characteristics should follow etiology linked by “as evidenced by” (AEB)
- Write in legally advisable terms
- Use non-judgmental language
- Problem statement states what is unhealthy or what patient wants to enhance
- Reread the diagnosis, ensure problem statement suggests outcomes and etiology directs selection of nursing measures
guidelines for writing a nursing diagnosis
identifies what is unhealthy about the patient, indicating the need for change (clear, concise statement of the patient’s health problem)
problem (nursing diagnosis)
suggests the patient outcomes (expectations for change)
purpose of problem (nursing diagnosis)
identifies the factors that are maintaining the unhealthy state or response (contributing or causative factors)
etiology (nursing diagnosis)
suggests the appropriate nursing measures
purpose of etiology
identify the subjective and objective data that signal the existence of the problem (cues that reflect the existence of a problem)
defining characteristics (nursing diagnosis)
suggest evaluative criteria
purpose of defining characteristics (nursing diagnosis)
Which of the following nursing diagnoses is written correctly?
A) Child abuse related to maternal hostility
B) Breast cancer related to family history
C) Deficient knowledge related to alteration in diet
D) Imbalanced nutrition related to insufficient funds in meal budget
D
A nursing is caring for a pt who presents with labored respirations, productive cough, and fever. What would be the appropriate nursing diagnoses for this patient? Select all that apply
A) Bronchial Pneumonia
B) Impaired gas exchange
C) Ineffective airway clearance
D) Infection related to pneumonia
E) Risk for septic shock
B, C, E
A nurse makes a clinical judgement that an African American man in a stressful job is more vulnerable to developing hypertension than a white man in the same or a similar situation. The nurse has formulated what type of nursing diagnosis?
Risk
- establish priorities
- identify expected patient outcomes
- select evidence-based nursing intervention
- take into consideration patient and nurse capabilities, time, and resources
Outcome identification and planning
- Individualized, patient-centered care (or person-centered care)
- Prioritization
- Bias
- Scope of standards of nursing practice
- EBP
- Realistic, specific, and measurable
- Consider long-term vs. short-term
Keep “big picture) in focus: consider discharge goals
choosing outcomes and interventions
- Holistic
- Assess how patient is doing at every encounter
- Partner with patient using shared decision making
- Patient +/- family actively participate in own care
- Open communication with respect and compassion
individualized, patient-centered care
- full transparency and fast delivery of information
- mission and values aligned with patient goals
- care is collaborative, coordinate, accessible
- physical comfort and emotional well-being are top priorities
- patient and family viewpoints respected and valued
- patient and family always included in decisions
- family welcoming in care setting
patient-centered care
The nurse enters the room of a 32 y/o pt new cancer (CA) dx at 1900. pt scheduled for surgery in AM. Pt observed talking with mother and crying, stating “this is so unfair”; states that she has so many questions. Order in chart: bowel prep enema to be given during night shift. Pre-op checklist to be completed. The nurse establishes priorities for which of the following situations first?
A) Begin enema
B) Talk with patient about past experiences with illness
C) Talk with patient about concerns and acknowledge her sense of unfairness
D) Begin reviewing pre-operative checklist with patient
C
- what problems need immediate attention and which ones can wait?
- ABC
- Maslow’s hierarchy
- Which problems are your responsibility and which do you need to refer to someone else?
- which problems can be dealt with by using standard plans (e.g. critical paths, standards of care)?
prioritization
basic needs
1) physiological needs: food, water, warmth, rest
2) safety needs: security, safety
psychological needs
3) belongingness and love needs: intimate relationships, friends
4) esteem needs: prestige and feeling of accomplishment
self-fulfillment needs
5) self-actualization: achieving one’s full potential, including creative activities
Maslow’s hierarchy
Which nursing diagnosis would most likely to be considered a high priority?
A) Acute pain
B) Impaired gas exchange
C) Risk for powerlessness
D) Activity intolerance
B
Practice in a manner that is congruent with cultural diversity and inclusion principles
bias
- Nursing school clinicals
- Employer protocols
- American Nurses Association (ANA): 3rd edition Nursing scope of practice
- State board of nursing
- Agency for healthcare research and quality (AHRQ)
- Quality and Safety Education for Nurses (QSEN)
- Joint Commission on Accreditation of Healthcare Organizations (JACHO)
scope of practice and standards of care
- PICO
- MEDLINE and CINAHL
- appraise: valid? important? relevant?
- integrate with clinical expertise and patient preference
evidence-based practice ideal
rely on protocols and guidelines
reality of evidence-based practice
- Using goals, objectives, and outcomes interchangeably
- Ex) For dx of acute pain “following administration of PRN analgesic, patient will report pain absent or diminished”
specific goals
- often means discharge planning that begins at admission and accounts for self-care at home
- Ex) Mrs. Goldstein returns to long-term care facility pain free with her incision healed and her left leg in good alignment
long-term goals
- Ex) whenever observed, pt will be lying in bed with legs in correct alignment (abductor pillow in place, if ordered)
- Ex) Before discharge, Mrs. Goldstein’s hip incision will show signs of healing (skin surface approximate, free from signs of infection-redness, swelling, heat, purulent drainage)
short-term goal
1) expressing pt outcome as nursing intervention
2) using verbs that are not observable or measurable
3) including more than one pt behavior or manifestation in short-term outcomes
4) writing vague outcomes
common errors in writing pt outcomes
- carry out the plan
- continue data collection and modify the plan of care as needed
- document care
- taking into consideration developmental age and psychosocial background, ability and willingness to participate, and response to nursing measures and progress toward goal achievement
implementation
1) patient variables - developmental stage (ex. Alzheimer’s pt) and psychosocial background/culture
2) nursing variables - resources? time? staff?, standards of care, questionable orders, anticipation
factors that could inhibit implementation
Which example illustrates a nurse variable influencing patient outcomes?
A) A patient in a SNF refuses to take their medications
B) A family whose monthly income falls below the poverty level is unable to afford formula for their newborn infant
C) A patient with alcoholism is unwilling to participate in AA meetings
D) A victim of sexual assault does not receive counseling in the emergency department because a counselor is not available
D
- Low value attached to outcomes
- Lack of understanding about the beliefs
- Lack of social support
- Adverse physical or emotional effects of treatment
- Inability to afford treatment
- Limited access to treatment
factors of patient nonadherance
- Assess –> Re-assess –> Revise –> Record
- Know the difference between direct and indirect care interventions
implementation phase
both physiological and psychosocial action; laying hands; direct care; interaction with pt
ex) Assisting with ambulating; Administering medication
direct intervention
intervention performed away from pt but on behalf of the pt
ex) consultation, calling social worker or case manager, ordering labs, prepping meds/Ivs
indirect intervention
- Right task
- Right circumstance
- Right person
- Right directions and communication
- Right supervision and evaluation
considerations when delegating nursing care
- clinical assessment
- initial client education
- discharge education
- clinical judgment
- initiating blood transfusion
- psychosocial support
RN scope of practice
- monitoring RN findings
- reinforcing education
- routine procedures (catheterization)
- most medication administrations
- ostomy care
- tube latency and enteral feeding
- specific assessments (eg. lung sounds, bowel sounds, neuromuscular checks)
LPN/LVN scope of practice
- activities of daily living
- hygiene
- linen change
- routine, stable vitals
- documenting input/output
- positioning
UAP scope of practice
The nurse is about to begin implementing care plan for 16 y/o patient with infant born prematurely 12 hours ago. Patient states “we will be fine on our own, I don’t need any care right now.” What is the nurse’s best response?
A) “You know your personal situation better than I do, so I will respect your wishes”
B) “If you don’t accept this help, your baby’s health might suffer”
C) “Let’s take a look at this plan together and see if we can fix it to meet your needs”
D) “I’m going to set a meeting with the social worker to talk to you”
C
True or False: When a patient fails to cooperate with the care plan despite the nurse’s best efforts, it is time to reassign the patient to another caretaker
False
- measure how well the pt has achieved desired outcomes
- identify factors contributing to the patient’s success or failure
- modify the plan of care, if indicated
Evaluation
- Interpreting and summarizing findings
- Collecting data to determine whether evaluate criteria and standards are met
- Documenting your judgment (evaluative statement)
- Terminating, continuing, or modifying the plan
- Identifying evaluate criteria and standards (expected patient outcomes)
elements of evaluation
A nurse uses the classic elements of evaluation when care for patients. What is the correct order?
- Interpreting and summarizing findings
- Collecting data to determine whether evaluative criteria and standards are met
- Documenting your judgment (evaluative statement)
- Terminating, continuing, or modifying the plan
- Identifying evaluative criteria and standards (expected patient outcomes)
5,2,1,3,4
1) Nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan
2) The nurse identifies factors that contribute to the patient’s ability to achieve expected outcomes and when necessary, modifies the care plan. Includes ongoing assessment
Evaluation steps
allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions
purpose of evaluation
A nurse is writing an evaluative statement for a patient who is trying to lower cholesterol through diet and exercise. Which statement is written correctly?
A) “outcome not met”
B) “1/21/20 - patient reports no change in diet”
C) “Outcome not met. Patient reports no change in diet or activity level”
D) “1/21/20 - Outcome partially met. Patient reports increased activity since last visit, but no change in diet”
D
