Exam #2 Flashcards
Stereotyping
One assumes that all members of a culture, ethnic group or race act alike.
Includes:
-ageism
-racism
-sexism
Cultural imposition
Belief that someone should conform to your own belief system
Cultural blindness
When one ignores differences and proceeds as though they do not exist
Cultural Conflict
People become aware of cultural differences, feel threatened and respond by ridiculing the beliefs and traditions of others
Cultural assimilation
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.
Culture shock
When a person is placed in a different culture that he or she perceives as strange
Result in:
-psychological discomfort
Ethnocentrism
The belief that the ideas beliefs and practices of one’s own culture are superior to those of anothers’
Physiologic variations
Certain racial and ethnic groups are more prone to certain diseases and conditions
Reactions to pain
May be culturally influenced
(Pain is weakness)
(Some cultures encourage open expressions of pain)
Mental Health
Many ethnic groups have their own norms and accepable patterns of behavior for psychological well-being
Different normal psychological reaction to certain situations
biological sex roles
Man is dominant in most cultures, knowing who is dominant in the family is important!
Health disparities
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
Interpreters
-use facility approved interpreters
DO NOT ALLOW FAMILY/FRIENDS TO INTERPRET
Nonverbal
Use nonverbal communication with cation because it may have a different meaning to the client depending on their culture
Apologize
Apologize if cultural traditions or beliefs are violated
Family patterns & Gender roles
Communicate with and include the person who has the authority to make decisions in the family
Clinical reasoning
Refer to ways of thinking about patient care issues
-determining
-preventing & managing patient problems
Clinical Judgement
Refers to the result (outcome) of critical thinking or clinical reasoning
-conclusion
-decision
-opinion
That you made
Nursing process
-assess
-diagnose
-plan
-implement
-evaluate
** A.D.P.I.E. **
(Systemic) Characteristics of the nursing process
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.
(Dynamic) Characteristics of the nursing process
The nursing process is presented as an orderly progression of steps
Great interaction and overlapping among the 5 steps
(Intrapersonal) Characteristics of the nursing process
The nursing process insures that nurses are person centered rather than task oriented
(Outcome oriented) Characteristics of the nursing process
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
Universally applicable in nursing situations
Mastering the nursing process gives you a valuable tool you can use with ease in any nursing situation
Assessment
Gather data that you will use to draw conclusions about the clients health status
Diagnosis
(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
Planning outcomes
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
Planning Interventions
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.
Implementation
Plan in action
evaluation
Determine if the goals were met, partially met, or not met.
Initial assessment
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
Focused assessment
Data gathered about a specific problem that has already been identified. Routinely part of ongoing data collection
Emergency Assessment
When a person presents with a psychological or physiologic crisis
IDENTIFY LIFE THREATENING PROBLEMS
Time-Lapsed assessment
Periodic assessments usually in long-term care. To reassess their health status and to make necessary revisions to the care plan.
Subjective data
What the patient tells you
Objective data
What the nurse sees, hears, measures or observed
-physiologic
-pychologic
-developmental
-environmental
Primary source of data
Client
Gordon’s functional health patterns
-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
Assessment ENTAILS
Collect data
Identify cues and make inferences
Validating data
Clustering related data and identifying patterns
Reporting and recording data
Diagnosing
Cluster or group data
Identify strengths and problem
Identify potential complications
Reaching conclusions
Actual Nursing Diagnosis, Problem-Focused
Problem that has been validated
-Has major defining characteristics
Risk Nursing Diagnosis
-Client is more vulnerable to develop the problem
Health Promotion Diagnosis
-Present status or function is effective
-Desire for a higher level of wellness
Syndrome Nursing Diagnosis
-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
Problem (NANDA)
Etiology: cause
Etiology: cause
As evidenced by (AEB) or
As manifested by
Defining Characteristics
Subjective & objective data that provides evidence
Criteria for prioritizing
A, B, C
Maslow’s Hierarchy of Human Needs
Patient Preference
Anticipation of Future Problems
Individualize
Individualize care that maximizes outcome achievement
Set
Set priorities
Facilitate
Facilitate communication among nursing personnel and colleagues
Promote
Promote continuity of high-quality, cost-effective care
Coordinate
Coordinate care
Evaluate
Evaluate patient response to nursing care
Create
Create a record used for evaluation, research, reimbursement, and legal reasons
Promote
Promote nurse’s professional development
Initial Planning:
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
Ongoing Planning:
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
Discharge Planning:
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
Cognitive outcome
Cognitive outcome describes an increase in patient knowledge or intellectual behaviors. This can be asking the client to repeat information or to apply knowledge.
Psychomotor outcomes
Psychomotor outcomes describe the patient’s achievement of new skills. This can be asking a client to demonstrate the new skill.
Affective outcomes
Affective outcomes describe changes in patient values, beliefs and attitudes. Affective outcomes are more complex, must observe client behavior and conversation.
Physiologic outcome
Physiologic outcome measuring the change, assess for skin changes, ect.
S.M.A.R.T. Outcomes
S – specific, individualized to the patient
M – measurable
A – attainable
R – realistic
T – time-bound
Nurse-Initiated (nursing intervention)
Actions performed by a nurse without MD order.
Physician-Initiated Interventions
Actions initiated by the physician in response to a medical dx but carried out by a nurse under doctor’s orders.
Collaborative Interventions
Treatments initiated by other providers and carried out by a nurse.
Characteristics of nursing interventions
-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.
Implementation
Carry out nursing interventions
Documentation
Document all nursing actions/assessments
Document patient responses
5 Rights of delegation
- Right Task
- Right Circumstances
- Right Person
- Right Directions and Communication
- Right Supervision and Evaluation
Evaluation
Did your client meet his or her goals? Why or why not? What modifications (if any) need to be done?
The five classic elements of evaluation are:
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
Evaluative Statements
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.
Revisions in the Care Plan
-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
Micturition/Voiding
is the process of emptying the bladder, also known as urination or voiding.
Process of emptying/voiding/urinating
Detrusor muscle contracts
Internal sphincter relaxes
Urine enters posterior urethra
Painless
Frequency
Usually, every 3-4 hours
Kidneys concentrate urine during sleep
** Urinary output should be >30ml/hr. 8 hour shift =min. 240ml urine output **
Factors that Affect Urinary Elimination
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
Aging
-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.
Physiological Factors Affecting Urinary Elimination
Neurological integrity
Fluid intake volume
Food intake
Fluid loss from other routes
Intra-abdominal pressure
Activity (immobility)
Decreased bladder & sphincter tone
Psychological Factors Affecting Urinary Elimination
Anxiety and stress
Pain
Renal Problems
Congenital abnormalities of urinary tract
Polycystic kidney disease, UTI, renal calculi (kidney stones)
Hypertension, Diabetes Mellitus
Gout, Connective Tissue Disorders
Other conditions affecting urinary elimination
Arthritis – DJD, Parkinson’s Disease
Cognitive deficits & some psychiatric problems
Fever & diaphoresis, Congestive Heart Failure
Medications Affecting Urinary Elimination
Nephrotoxic drugs – cause kidney damage
Diuretics & cholinergic medications
Analgesics & tranquilizers
Some drugs can change urine color
