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Nursing Fundamentals > Exam #2 > Flashcards

Exam #2 Flashcards

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1
Q

Stereotyping

A

One assumes that all members of a culture, ethnic group or race act alike.

Includes:
-ageism
-racism
-sexism

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2
Q

Cultural imposition

A

Belief that someone should conform to your own belief system

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3
Q

Cultural blindness

A

When one ignores differences and proceeds as though they do not exist

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4
Q

Cultural Conflict

A

People become aware of cultural differences, feel threatened and respond by ridiculing the beliefs and traditions of others

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5
Q

Cultural assimilation

A

When a minority group lives within a dominant group, many members may lose the cultural characteristics that once made them different

They take on the values of the dominant culture.

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6
Q

Culture shock

A

When a person is placed in a different culture that he or she perceives as strange

Result in:
-psychological discomfort

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7
Q

Ethnocentrism

A

The belief that the ideas beliefs and practices of one’s own culture are superior to those of anothers’

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8
Q

Physiologic variations

A

Certain racial and ethnic groups are more prone to certain diseases and conditions

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9
Q

Reactions to pain

A

May be culturally influenced
(Pain is weakness)
(Some cultures encourage open expressions of pain)

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10
Q

Mental Health

A

Many ethnic groups have their own norms and accepable patterns of behavior for psychological well-being

Different normal psychological reaction to certain situations

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11
Q

biological sex roles

A

Man is dominant in most cultures, knowing who is dominant in the family is important!

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12
Q

Health disparities

A

Health differences or gap between groups of people

They can affect how frequently a disease affects a group, how many people get sick, or how often the disease causes death

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13
Q

Interpreters

A

-use facility approved interpreters

DO NOT ALLOW FAMILY/FRIENDS TO INTERPRET

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14
Q

Nonverbal

A

Use nonverbal communication with cation because it may have a different meaning to the client depending on their culture

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15
Q

Apologize

A

Apologize if cultural traditions or beliefs are violated

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16
Q

Family patterns & Gender roles

A

Communicate with and include the person who has the authority to make decisions in the family

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17
Q

Clinical reasoning

A

Refer to ways of thinking about patient care issues

-determining
-preventing & managing patient problems

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18
Q

Clinical Judgement

A

Refers to the result (outcome) of critical thinking or clinical reasoning

-conclusion
-decision
-opinion
That you made

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19
Q

Nursing process

A

-assess
-diagnose
-plan
-implement
-evaluate

** A.D.P.I.E. **

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20
Q

(Systemic) Characteristics of the nursing process

A

Each nursing activity is part of an ordered sequences of activities
-each activity depends on the accuracy of the activity that precedes it and influences the actions that follow.

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21
Q

(Dynamic) Characteristics of the nursing process

A

The nursing process is presented as an orderly progression of steps

Great interaction and overlapping among the 5 steps

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22
Q

(Intrapersonal) Characteristics of the nursing process

A

The nursing process insures that nurses are person centered rather than task oriented

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23
Q

(Outcome oriented) Characteristics of the nursing process

A

Nurses and patients work together to identify specific outcomes related to health, to determine which outcomes are most important to the patient and match them with appropriate nursing actions

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24
Q

Universally applicable in nursing situations

A

Mastering the nursing process gives you a valuable tool you can use with ease in any nursing situation

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25
Q

Assessment

A

Gather data that you will use to draw conclusions about the clients health status

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26
Q

Diagnosis

A

(Analysis)
Identify the clients health needs (usually stated in the form of a problem) based on careful review of your assessment data
-analyze all your data
-synthesize/cluster info
-hypothesize about you clients health status

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27
Q

Planning outcomes

A

Making decisions about goals for your care, the client outcomes you want to achieve through your nursing activities

Outcomes will drive your choice of interventions

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28
Q

Planning Interventions

A

Developing a list of all possible interventions based on our nursing knowledge and then choosing the most likely to help the client achieve the stated goals.

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29
Q

Implementation

A

Plan in action

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30
Q

evaluation

A

Determine if the goals were met, partially met, or not met.

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31
Q

Initial assessment

A

Performed shortly after patient admitted. Establish a complete database for problem identification and care planning.

-The nurse collects data concerning all aspects of the patient’s health, establishing priorities for ongoing focused assessment and creating a reference baseline for future comparison

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32
Q

Focused assessment

A

Data gathered about a specific problem that has already been identified. Routinely part of ongoing data collection

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33
Q

Emergency Assessment

A

When a person presents with a psychological or physiologic crisis

IDENTIFY LIFE THREATENING PROBLEMS

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34
Q

Time-Lapsed assessment

A

Periodic assessments usually in long-term care. To reassess their health status and to make necessary revisions to the care plan.

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35
Q

Subjective data

A

What the patient tells you

36
Q

Objective data

A

What the nurse sees, hears, measures or observed
-physiologic
-pychologic
-developmental
-environmental

37
Q

Primary source of data

A

Client

38
Q

Gordon’s functional health patterns

A

-Health perception/health management
-nutritional/metabolic
-Elimination
-Activity/exercise
-Cognitive-perceptual
-Sleep/rest
-Self-perception/Self-concept
-role/relationship
-Sexulity and reproductive
-coping/tress tolerance
-value belief

39
Q

Assessment ENTAILS

A

Collect data
Identify cues and make inferences
Validating data
Clustering related data and identifying patterns
Reporting and recording data

40
Q

Diagnosing

A

Cluster or group data
Identify strengths and problem
Identify potential complications
Reaching conclusions

41
Q

Actual Nursing Diagnosis, Problem-Focused

A

Problem that has been validated
-Has major defining characteristics

42
Q

Risk Nursing Diagnosis

A

-Client is more vulnerable to develop the problem

43
Q

Health Promotion Diagnosis

A

-Present status or function is effective
-Desire for a higher level of wellness

44
Q

Syndrome Nursing Diagnosis

A

-Clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions
-Chronic pain syndrome is an example

45
Q

Problem (NANDA)

A

Etiology: cause

46
Q

Etiology: cause

A

As evidenced by (AEB) or
As manifested by

47
Q

Defining Characteristics

A

Subjective & objective data that provides evidence

48
Q

Criteria for prioritizing

A

A, B, C

Maslow’s Hierarchy of Human Needs

Patient Preference

Anticipation of Future Problems

49
Q

Individualize

A

Individualize care that maximizes outcome achievement

50
Q

Set

A

Set priorities

51
Q

Facilitate

A

Facilitate communication among nursing personnel and colleagues

52
Q

Promote

A

Promote continuity of high-quality, cost-effective care

53
Q

Coordinate

A

Coordinate care

54
Q

Evaluate

A

Evaluate patient response to nursing care

55
Q

Create

A

Create a record used for evaluation, research, reimbursement, and legal reasons

56
Q

Promote

A

Promote nurse’s professional development

57
Q

Initial Planning:

A

Developed by the nurse who performs the nursing history and physical assessment
Addresses each problem listed in the prioritized nursing diagnoses/clinical problems
Identifies appropriate patient goals and related nursing care

58
Q

Ongoing Planning:

A

Carried out by any nurse who interacts with patient
Keeps the plan up to date, manages risk factors, promotes function
States nursing diagnoses/clinical problems more clearly
Develops new diagnoses/clinical problems
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals

59
Q

Discharge Planning:

A

Carried out by the nurse who worked most closely with the patient
Begins when the patient is admitted for treatment
Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently

60
Q

Cognitive outcome

A

Cognitive outcome describes an increase in patient knowledge or intellectual behaviors. This can be asking the client to repeat information or to apply knowledge.

61
Q

Psychomotor outcomes

A

Psychomotor outcomes describe the patient’s achievement of new skills. This can be asking a client to demonstrate the new skill.

62
Q

Affective outcomes

A

Affective outcomes describe changes in patient values, beliefs and attitudes. Affective outcomes are more complex, must observe client behavior and conversation.

63
Q

Physiologic outcome

A

Physiologic outcome measuring the change, assess for skin changes, ect.

64
Q

S.M.A.R.T. Outcomes

A

S – specific, individualized to the patient
M – measurable
A – attainable
R – realistic
T – time-bound

65
Q

Nurse-Initiated (nursing intervention)

A

Actions performed by a nurse without MD order.

66
Q

Physician-Initiated Interventions

A

Actions initiated by the physician in response to a medical dx but carried out by a nurse under doctor’s orders.

67
Q

Collaborative Interventions

A

Treatments initiated by other providers and carried out by a nurse.

68
Q

Characteristics of nursing interventions

A

-action statement that starts with an action verb.
-answer who, what, how, when, where, how often, how much, and how long.
-assist the client in meeting specific outcomes and be individualized to the client.
-always be well documented in the care plan and signed by the RN.

With any intervention that we do, it should be evidence-based.

69
Q

Implementation

A

Carry out nursing interventions

70
Q

Documentation

A

Document all nursing actions/assessments
Document patient responses

71
Q

5 Rights of delegation

A
  1. Right Task
  2. Right Circumstances
  3. Right Person
  4. Right Directions and Communication
  5. Right Supervision and Evaluation
72
Q

Evaluation

A

Did your client meet his or her goals? Why or why not? What modifications (if any) need to be done?​

73
Q

The five classic elements of evaluation are:​

A

Identifying evaluative criteria and standards (what you are looking for when you evaluate – i.e. expected patient outcomes)​
Collecting data to determine whether these criteria and standards are met​
Interpreting and summarizing findings​
Documenting your judgment​
Terminating, continuing or modifying the plan​

74
Q

Evaluative Statements

A

When evaluating the patient’s care plan, you need to determine how well the outcome was met. Was it met, partially met or not met. Include the patient data or behaviors that support your decision.

75
Q

Revisions in the Care Plan

A

-delete or modify the nursing diagnosis/clinical problem
-make the outcome statement more realistic
-increase the complexity of the outcome statement
-adjust time criteria in the outcome statement
-change nursing interventions

76
Q

Micturition/Voiding

A

is the process of emptying the bladder, also known as urination or voiding.

77
Q

Process of emptying/voiding/urinating

A

Detrusor muscle contracts
Internal sphincter relaxes
Urine enters posterior urethra
Painless

78
Q

Frequency

A

Usually, every 3-4 hours
Kidneys concentrate urine during sleep

** Urinary output should be >30ml/hr. 8 hour shift =min. 240ml urine output **

79
Q

Factors that Affect Urinary Elimination

A

Developmental
-Infant’s urine is typically light in color and odorless. Infants are born with little ability to concentrate urine.
Toilet Training Readiness
-Voluntary control of urethral sphincters~18-24m (Training at 2-3yrs old)
-Hold urine for 2 hours
-Recognize feeling of bladder fullness
-Communicate need to void
-Desire to use toilet
-Cultural approaches vary

80
Q

Aging

A

-Bladder perineal muscles – inability to hold urine or inability to empty bladder
-Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of UTI.
-Getting to the toilet is affected by neuromuscular problems, Degenerative Joint Disease, thought changes, weakness
-The bladder also has a decreased ability to concentrate urine which results in nocturia.

81
Q

Physiological Factors Affecting Urinary Elimination

A

Neurological integrity
Fluid intake volume
Food intake
Fluid loss from other routes
Intra-abdominal pressure
Activity (immobility)
Decreased bladder & sphincter tone

82
Q

Psychological Factors Affecting Urinary Elimination

A

Anxiety and stress
Pain

83
Q

Renal Problems

A

Congenital abnormalities of urinary tract
Polycystic kidney disease, UTI, renal calculi (kidney stones)
Hypertension, Diabetes Mellitus
Gout, Connective Tissue Disorders

84
Q

Other conditions affecting urinary elimination

A

Arthritis – DJD, Parkinson’s Disease
Cognitive deficits & some psychiatric problems
Fever & diaphoresis, Congestive Heart Failure

85
Q

Medications Affecting Urinary Elimination

A

Nephrotoxic drugs – cause kidney damage
Diuretics & cholinergic medications
Analgesics & tranquilizers
Some drugs can change urine color

Nursing Fundamentals (8 decks)

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