Exam 1 Questions Flashcards
The Practitioner
Transforms the practice culture through application of discipline-specific work in a manner that ensures regulatory and specialty standards are used in the provision of care and service in a therapeutic manner. Review the American Nurses Association Standards of Practice.
O’Rourke Model of the Professional Role
The Professional Practice Model is a schematic that describes how we, in our nursing role, practice, collaborate, communicate, and develop professionally. It is the foundation for the structure of professional nursing at OHSU and the integrated professional activities performed within that structure. It is creating and fostering a professional practice environment in which a culture exists that supports inquiry, self-reflection, professional development, and peer review in service to improving the unit and organization for all who are present.
What are the different stages of the Nursing Process
AAPIE Assessment Analysis Planning Implementation Evaluation
determine a desired outcome (short term or long term) and create a Nursing Care Plan (NCP)
Planning :
interpret the data to make a nursing diagnosis
Analysis:
: Execute the interventions in order to fulfill the NCP
Implementation
determine if the interventions are working based on the reactions of the client. Do the observable results/statements support success in achieving a desired outcome?
Evaluation:
acquired from the client directly
Primary data
acquired from a family member or someone else on the health team
Secondary data:
this type of data is measurable and indisputable…is considered client focused
Objective data (signs)
What are these all examples of?
Vital signs, weight, skin condition, input/output, lab values, observations of a patient’s behavior /environment (patient’s assessment is considered this too)
Objective Data
what the patient reports to you:
not necessarily measureable, nausea, headaches, dizziness and pain (patient history is considered this too)
Subjective data (symptoms):
is based on a patient’s medical condition or disease
medical diagnosis
is based on patient’s response to an actual or potential health problem
nursing diagnosis
is used to select interventions
diagnosis (either nursing or medical)
What does a nursing diagnosis include?
- P (problem)—NANDA-I label—Example: impaired physical mobility
- E (etiology or related factor)—Example: incisional pain
- S (symptoms or defining characteristics)—briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning page 230
This stage is necessary to measure how effective your nursing interventions are. It is used to determine if the nursing plan and goals are still appropriate. If not, it is essential to modify them accordingly in order to match the patient’s current condition. It is important to record the patient’s responses as well.
Evaluation
Nurses initiate on the basis of their knowledge and skills (scope of practice).
scope like assessing, comfort, emotional support, counseling & teaching
Activities such as skin tests, immunizations, and human blood draws are considered as independent functions (2725 b3). Observing patients’ overall condition - signs and symptoms of sickness, conduct and physical factors (2725 b4A); and responding to these observations given proper endorsement and standardized procedures, changes in patient care or in times of emergency measures (2725 b4) also cover independent functions of the nursing practice.
examples:
Teach the client to do deep breathing and coughing exercise.
Monitoring blood pressure
Independent interventions
Nurse carries out under a doctor’s order (medication or treatments)
“we need to talk…” doctor says to the nurse then nurse administers…
examples:
Administer antipyretic medication as ordered by the physician.
Administer 4 liters of oxygen as ordered.
Dependent Interventions
Nurse carries out with other health care professionals (example psychologists, pharmacists, nutritionists, radiologists, anesthesiologist, physical therapists, medical technologists, etc)
example:
Administer of total parenteral nutrition. The nutritionist is involved in the intervention.
Collaborative Interventions (also called Interdependent Nursing Intervention)
Who has access to patient data?
health care providers for treatment
patient or the patient’s personal representative it was permitted authorization/consent
HHS for complaint investigation, compliance review or enforcement; required by law for compliance with the HIPAA Transactions Rule or other HIPAA Administrative Simplification Rules
Others (reasonable reliance consent by the patient)
a public official, a professional (such as an attorney or accountant) who is the covered entity’s business associate, seeking the information to provide services to or for the patient, a researcher who provides the documentation or representation required by the Privacy Rule for research
What kind of Data is recorded in patient files?
the minimum amount of protected health information needed to accomplish the intended purpose of the use disclosure, or request.
What are the interviewing skills?
Plan the time and place of the interview
Allow the exchange to be uninterrupted and unhurried be at eye level
Assure confidentiality
What are the stages of the interview
(1) setting the stage, (2) gathering information about the patient’s chief concerns or problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview. (Potter 212)
What are acceptable temperature ranges for adults?
36° to 38° C (96.8° to 100.4° F)
What are acceptable respiration ranges for adults?
12 to 20 breaths/min
Which temperature methods are body core readings?
oesophagus, pulmonary artery or urinary bladder
Which temperature methods are body surface readings?
oral, axillary, temporal, tympanic
What is average blood pressure for adults?
Average: <120/80 mm Hg
How do you calculate pulse pressure?
Pulse pressure= (Systolic - Diaystolic):
What is the average pulse pressure of an adult?
30 to 50 mm Hg
What is the average pulse of an adult?
60 to 100 beats per minute
Which sites are more accurate temperature readings? Core sites or surface sites?
Core sites
easily accessible, comfy, accurate surface reading, reflect rapid change in core temp, reliable in intubated pt, delay if pt recently ingested food/liquid, not for oral surgery/facial trauma, not for infants, kids, confused, risk for body fluid exposure
Oral temperature reading
Where do you place the probe stem with plastic cover to get a temp reading orally?
posterior sublingual pocket lateral to center
this temperature reading method is easily accesible, get without disturbing pt, pt with tachypnea w/o disturbing breathing, accurate core reading, 2-5 sec, unaffected by intake food/liquid, used in newborns, variability of measurement, need to remove hearing aid, not for ear surgery pt, affected by ambient temp devices (heater, fans), hard to do in kids
Tympanic
How do you get a tymApanic temperature reading?
right ear if right handed, left ear if left handed, ear wax?, slide disposable cover over lens tip until locks, pull ear pinna backward, up, and out, fit tip snug, point toward nose, press scan, beeps
this temperature readinng method is reliable, lag behind core temp during rapid change, not for diarrhea/rectal surgery, requires positioning, risk for body fluid exposure, requires lube, not for infants, impacted stool mess up readings, invasive
Rectal temp reading
safe/inexpensive, for newborns, unconscious, long measurement time, continuous positioning, measurement lags behind core temp during rapid temp change, not for fever in kids, exposure of thorax, temp loss in newborns, underestimates core temp
axilla temp reading
draw curtains, supine or sitting, move clothing, probe stem to plastic cover until it locks, raise pt arm, dry axilla if needed, put probe into center of axilla, lower arm over probe, arm across chest, hold until it beeps
method of axilla reading
easy, rapid, comfy, no need to disrobe, for premmies, newborns, kids, reflects rapid change in core temp, sensor cover not required, inaccurate with head covering, affected by skin moisture
method of temporal temp reading
dry forehead, sensor firmly on forehead, red scan button, slide across forehead, sensor flat and firmly on skin, clean sensor
temporal temperature reading
increase heat loss, reduce heat production, prevent complications; interventions - blood cultures, min heat production - limit physical activity, max heat loss - reduce coverings, keep clothing/bed linen dry, antipyretics, maybe drug sensitivity, antibiotics maybe, environment temp 70-80,
method for treating a fever
Means the same as evaluation
Conducting reflective practice
(analyzing information, gathering additional findings, and sensing a problem), and self-confidence
Critical thinking concepts
Pain scale is an example of which intellectual standard
Consistency
a symptom that occurs along with a primary symptom
concomitant symptom: an accessory symptom to the primary symptom
an immunization shot is an example of what type of prevention
Primary prevention
rimary prevention involves preventing risk factors that lead to chronic diseases, infections and injuries. Types of primary prevention include vaccination, condom usage, and nutrition. Secondary prevention reacts to prevent further exacerbation of a known problem. Types of activities used in secondary prevention include using medication to treat conditions such as high blood pressure or high cholesterol
What is always patient centered?
The goal (nothing is care provider centered)
What is the goal for an “at risk diagnosis”
to avoid or prevent the condition at risk (referr question 5 CH 20)
What is the goal for a nursing diagnosis
Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding the patient’s needs
- Allows nurses to communicate (e.g., written and electronic) what they do among themselves with other health care professionals and the public
- Distinguishes the nurse’s role from that of the physician or other health care provider
- Helps nurses focus on the scope of nursing practice
- Fosters the development of nursing knowledge
- Promotes creation of practice guidelines that reflect the essence of nursing (Potter 224)
Engages in evidence-based clinical practice standards and performance; links professional role competency with clinical, service, and financial outcomes. Review the ANA Standards for Professional Practice related to Quality of Practice, Practice Evaluation, Education, and Research.
The Scientist Role
Exercises decision making authority that ensures role- and standards-based practice; champions quality improvement. Review the ANA Standards for Professional Practice related to Research Utilization, Ethics and Leadership. Review the ANA Code of Ethics.
The Leader Role
Acts in a manner that promotes dialogue, open communication and positive interdisciplinary working relationships. Review the ANA Standards for Collegiality and Collaboration.
The transferor of knowledge
What is the below process?
Data collection and Data assessment Comprehensive assessment of patient condition with DX Plan Implementation Evaluation Teaching
Decision making process (O’Rourke)
What is the difference between the “Nursing Process” and the “Decision making process by O”Rourke”
1) The Nursing Process has an “analyzing” step which performs a diagnosis- The Decision making process doesnt have this step
What is the below process?: Assessment Analysis Planning Implementation Evaluation
The Nursing process
: gathering data, like the patient’s health history in order to get objective as well as subjective information.
- Assessment
interpret the data to make a nursing diagnosis
- Analysis:
determine a desired outcome (short term or long term) and create a Nursing Care Plan (NCP)
- Planning:
Execute the interventions in order to fulfill the NCP
- Implementation:
determine if the interventions are working based on the reactions of the client. Do the observable results/statements support success in achieving a desired outcome?
- Evaluation:
What kind of Data is gathered in an assessment
primary vs secondary data
objective vs subjective
vital signs
What is a cue?
information obtained via you senses
What is an inference?
your judgement or interpretation of cues in your environment
What does the 11 functional health patterns represent?
represents the interaction of the patient and the environment-the patients strengths (advantages that a patient has to make his life better)
dysfunctional health patterns
this is what the nurse diagnoses, which is used to help make a nursing care plan
What does this list represent?:
Health perception–health management pattern: Describes patient’s self-report of health and well-being; how patient manages health (e.g., frequency of health care provider visits, adherence to therapies at home); knowledge of preventive health practices
Nutritional-metabolic pattern: Describes patient’s daily/weekly pattern of food and fluid intake (e.g., food preferences or restrictions, special diet, appetite); actual weight; weight loss or gain
Elimination pattern: Describes patterns of excretory function (bowel, bladder, and skin)
Activity-exercise pattern: Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
Sleep-rest pattern: Describes patterns of sleep, rest, and relaxation
Cognitive-perceptual pattern: Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability
Self-perception–self-concept pattern: Describes patient’s self-concept pattern and perceptions of self (e.g., self-concept/worth, emotional patterns, body image)
Role-relationship pattern: Describes patient’s patterns of role engagements and relationships
Sexuality-reproductive pattern: Describes patient’s patterns of satisfaction and dissatisfaction with sexuality pattern; patient’s reproductive patterns; premenopausal and postmenopausal problems
Coping–stress tolerance pattern: Describes patient’s ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance
Value-belief pattern: Describes patterns of values, beliefs (including spiritual practices), and goals that guide patient’s choices or decision
The 11 Functional Health Patterns…..the nurse tries to make an assessment of these functional health patterns to see if there is any dysfunction in any of the 11 functional patterns
Where is all assessment data recorded
Patient record
is made during the analysis stage (of nursing process) and is done by interpreting the assessment data, is based on patient’s response to an actual or potential health problem
Nursing Diagnosista
What are the parts of a nurse diagnosis
1) Diagnosis statement
eg: impaired verbal communication
2) etiology (what is causing the pain)
eg: related to cerebrovascular problems
3) Defining characteristic/symptoms
eg: as evidenced by slurred speech
What can a nurse diagnose?
acute pain, nausea, anything within the domain of nursing. something a nurse can competently treat
This stage (of the nursing process) is necessary to measure how effective your nursing interventions are. It is used to determine if the nursing plan and goals are still appropriate. If not, it is essential to modify them accordingly in order to match the patient’s current condition. It is important to record the patient’s responses as well.
Evaluation stage
What kind of statements are the following?:
-encourage a full description w/o trying to conrol the direction the story takes
example: “Is there anything else you can tell me?”
“What else is bothering you?”
remember to be observant. If pt becomes fatigue or uncomfortable, know when to postpone the interview
Probing
What kind of questions do you ask a patient when they are done answering your probing questions?
Close ended questions:
focus on the symptoms the pt identitfies and the general indigestion problem by asking closed-ended q’s
eg: examples: “Jow often does the diarrhea occur?” “Do you have pain or cramping?”
other examples:
• Who helps you at home?
• Do you understand why you are having the x-ray examination?
• Are you having pain now?
On a scale of 0 to 10, how would you rate your pain
Do you think the medication is helping you?
require short answers & clarifyprevious info or provide addtl info
acquire specific info (symptoms, precipitating factors, or relief measures
What are the most important cultural considerations to make
Never assume
Make sure patients know what you mean in their action and words
Level of eye contact varies from culture to culture (Europeans-direct eye contact), Asians-direct eye contact is rude and immodest, Americans- let their eye wander
increase heat loss; interventions - cooler environment, remove excess body clothes, cool wet towels over skin, fans, IV fluids, irrigate stomach and lower bowel with cool solutions, hypothermia blankets
Heatstroke intervention
prevent further decrease in body temp; interventions - warm blankets, hyperthermia blankets, remove wet clothing/linen, hot liquids, head covered, heating pads
Hypothermia intervention
What additional assessments do you make if you get an irregular pulse count?
Compare radial pulses bilaterally
What pulse irregularity are the following symptoms indicative of?
related data? fever, pain, fear, exercise, low B/P, blood loss, not enough oxygenation, abnormal cardiac function? dyspnea, fatigue, chest pain, orthopnea, syncope, palpitation, edema, cyanosis, pallor
tachycardia
less than 60 bpm are indicative of what pulse irregularity?
bradycardia
ventilation, movement of gases into and out of lungs, diffusion, movement of O2 and CO2 between alveoli and RBCs, erfusion, distribution of RBCs to and from pulmonary capillaries, observe rate, depth, rhythm of respiratory movements
Respirations
What alteration does the following describe?
respiration cease several sec, resp arrest
Apnea
What respiration alteration does the following describe?
rate of breathing regular but slow < 12/min
Bradypnea
What respiration alteration does the following describe?
resp rate/depth irregular, apnea and hyperventilation alternates
cheyne-stokes respiration
What respiration alteration does the following describe?
resp increased in depth, exercise
hyperpnea
What respiration alteration does the following describe?
rate and depth resp increase, low level of CO2 hypocarbia may occur
hyperventilation
What respiration alteration does the following describe?
irregular resp, vary in depth, intr
Biot’s respiration
What respiration alteration does the following describe?
resp rate abnormally low, depth ventilation depressed, hypercarbia, elevated CO2
hypoventilation
What respiration alteration does the following describe?
resp rapid, deep, regular, diabetic ketoacidosis
kussmaul’s respiration
What respiration alteration does the following describe?
rate of breathing reg, abnormally rapid >20/min
tachypnea
What is the normal oxygen saturation percentage?
95-100%
% to which hemoglobin filled with O2
Oxygen saturation percentage
Where are oxygen saturation readings taken on the body?
toe, finger, bridge of nose, forehead, earlobe,
note: not on same side as blood pressure cuff
force by blood against vessel walls, peak when contraction of heart, systole, when ventricles relax, blood remaining in arteries diastolic pressure
blood pressure
What are the three things that influence blood pressure?
1) blood volume - increase IV fluids elevate BP, hemorrhage/dehydration, BP falls
2) viscosity - hematocrit, rise - blood slows, BP increases
3) elasticity - prevents wid fluctuations in BP, lose elasticity, vessel don’t yield to pressure, systolic pressure more elevated than diastolic
the following BP reading is indicative of what type of blood pressure alteration?
120/80 or less
normal blood pressure
the following BP reading is indicative of what type of blood pressure alteration?
120-139/80-89
prehypertension
the following BP reading is indicative of what type of blood pressure alteration?
140-159/90-99
stage 1 hypertension
the following BP reading is indicative of what type of blood pressure alteration?
>160/>100
stage 2 hypertension
What are the four elements of physical assessment?
Inspection
Auscultation
Palpation
Percussion
When do you assess for Pain?
while you are taking vitals
What is the acronym used to assess pain?
P rovocation / Palliation - makes it worse, makes it better
Q uality - how does it feel, look, sound, what kind of pain, sharp, throbbing, dull, aching
R egion / Radiation - where is the pain, does it spread anywhere else
S everity / Scale - interfere with activities, ratio 1-10, also saw (0-10), 1 being not very painful, 10 being the most painful thing you ever felt, happy/sad faces
T ime / Onset - when did it begin, how often does it occur - comes and goes or constant, sudden or gradual
What do you inspect (inspection) for (data) in an assessment?
Moisture and color of the skin
Shape and symmetry of the body
Respiratory rate
Patient’s affect and appearance.
What do you auscultate for?
Breathe sounds
Abdominal sounds
Heart sounds
In an assessment, what do you palpate for?
Assess pulse rate
Abdominal assessment
Turgor
What kind of palpation do you use against skin/tissue, detect areas of irregularity and tenderness, , ½”
light palpation
What kind of palpation do you use to assess condition of underlying organs, be careful, 1”
deep palpation
Which element of physical assessment is used to assess by striking the body to get sounds it is performed over
Percussion
What are the parts of the body is percussion used for assessment?
Sinuses
Abdomen
Lungs
sounds
Percussion of the Gastric air bubble, puffed out cheek sounds like?
Tympany
Percussion of the Healthy lung sounds
Resonant
Percussion of the Emphyseamtous lung sounds
Hyperresonant
Percussion Over liver sounds
Dull
Percussion Over muscle sounds
Flat
What does the following define?
the protection, promotion, and optimaization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocay in the care of individuals, families, communities, and populations.
The definition of Professional Nursing
What are the three types of nursing diagnoses?
NANDA-I (2012) identifies three types of nursing diagnoses: actual diagnoses, risk diagnoses, and health promotion diagnoses. (Potter 227)
human responses to health conditions or life processes that exist in an individual, family, or community. Defining characteristics support the diagnostic judgment (Potter 228)
actual diagnosis, examples: Wandering,Impaired social interaction, Stress urinary incontinence
Risk nursing diagnosis
describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community (NANDA International, 2012). These diagnoses do not have related factors or defining characteristics because they have not occurred yet. Instead a risk diagnosis has risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem. examples: risk for loneliness, risk for acute confusion (Potter 228)
is a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise. Can be used in any health state and do not require current levels of wellness (Potter 228)
A health promotion nursing diagnosis, Examples of health promotion nursing diagnoses include:
- Readiness for enhanced family coping
- Readiness for enhanced nutrition (Potter 228)
Goal vs. outcome, give examples
A goal is a broad statement that describes a desired change in a patient’s condition or behavior. Mr. Jacobs has the diagnosis of deficient knowledge regarding his postoperative recovery. A goal of care for this diagnosis includes, “Patient expresses understanding of postoperative risks.”
An expected outcome is a measurable criterion to evaluate goal achievement. Once an outcome is met, you then know that a goal has been at least partially achieved. Sometimes several expected outcomes must be met for a single goal. Measurable outcomes for the goal of “understanding postoperative risks” include: “Patient identifies signs and symptoms of wound infection” (Potter 238)
Critical pathway
Critical pathways are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time); their main purpose is to deliver timely care at each phase of the care process for a specific type of patient (Espinosa-Aguilar et al., 2008). A critical pathway clearly defines transition points in patient progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficient as possible. (Potter 247)
Open Ended Questions
- it prompts pt to describe a situation in more than one or two words; pt actively describe their health status; strengthen relationship w/ pt
try to find out, in the pt own words, waht the health problem is and its probable cause
pt ususally the best resources in talking about symptoms (hx)
remember to encourage and let the pt tell the entire story
Example:
• Tell me how you are feeling.
Back Channeling
- example “alright”, “go on”, “uh-huh”
-good eye contact and listening skills
indicate that you have heard what the pt says and are interested
it encourages pt to give more details
Closed Ended Questions
Once a pt finishes his or her story use a problem-seeking interview, focus on the symptoms the pt identitfies and the general indigestion problem by asking closed-ended questions
examples: “How often does the diarrhea occur?” “Do you have pain or cramping?”
other examples:
• Who helps you at home?
Mental Status Exam parts
appearance - posture, body movement, dress, hygiene, grooming
behavior - LOC, A&O x4, person, place, time, event, facial expression, body language, mood and affect, speech
cognitive level - attention span, recent memory, new learning, judgement, thought process
Vital signs for the elderly, not numbers, differences in temp, heart rate, breathing, blood pressure vs. adults.
temp - does not change much, harder to regulate temp, less fat - harder to stay warm, reduced ability to sweat, fever risk, can’t get to a high temp, may seem like a normal temperature, but actually has a fever
HR - pulse same, longer for pulse to increase and longer to slow down after exercise
Breathing - same, lung function decrease
Blood pressure - risk of hypertension
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004424/
What to look for in a lesion?
ABCS - Asymetry, Border, Color, Size
What does planning involve?
Planning involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. P.237
Steps for evaluation
- Examine the outcome criteria to identify the exact desired patient behavior or response.
- Evaluate the patient’s actual behavior or response.
- Compare the established outcome criteria with the actual behavior or response.
- Judge the degree of agreement between outcome criteria and the actual behavior or response.
- If there is no agreement (or only partial agreement) between the outcome criteria and the actual behavior or response, what is/are the barrier(s)? Why did they not agree? P.270
