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NRSG 225- Intro > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

nursing diag. format

A

problem, “related to”, etiology/cause, “as evidenced by”, defining characteristics

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2
Q

risk for nursing diag format

A

“risk for”, problem, “related to”, etiology/cause

*no as evidenced by

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3
Q

skin functions

A 
protection
body core temp regulation
sensation
vitamin d production
immunological
absorption
elimination
psychosocial
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4
Q

layers of the skin-deep to superficial

A

dermis, epidermis

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5
Q

skin integrity factors

A

circulation, hydration

age or medications ex. steroids

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6
Q

skin developmental factors-infant and elderly

A

inc chance for injury

skin thins and becomes less elastic and resilient w/ age

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7
Q

wound characteristics- intentional v unintentional

A

planned/purposeful or on accident

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8
Q

wound characteristics- open or closed

A

is the dermis visible?

ex. closed= hematoma (bleeding underneath skin)

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9
Q

wound characteristics- acute v chronic

A

chronic wounds take longer to heal

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10
Q

wound definition

A

integrity of skin or mucous mem. is broken/ no longer intact

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11
Q

skin in immunologic defense

A

first line

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12
Q

asepsis used for wound care

A

clean/ medical and surgical (sterile)

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13
Q

tissue trauma results in what changes

A

local and systemic

= change in vital signs

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14
Q

nutrients needed for wound healing

A

protein and adeq. blood supply

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15
Q

roll of exudate in wound healing

A

needs to be removed along w/ o/ fluid or foreign material

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16
Q

wound healing- first phase

A 
hemostasis
constriction followed by dilation
immediately after tissue/skin injury
platelets attract o/ cells
exudate is formed= pain and swelling
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17
Q

wound healing- second phase

A

inflammatory
lasts 4-6 days
macrophages present, ingest debris and attract fibroblasts
acute inflammatory response = pain, heat, erythema and edema
fatigue is common*

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18
Q

wound healing- third phase

A 
proliferation
starts w/in 2-3 days of injury
capillaries grow across wound
thing layer epith cells forms
new tissue growth (granulation) and scar formation
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19
Q

wound healing- fourth phase

A

maturation
begins 3-6 weeks after injury
collegen tissue dev.
wound remodeling

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20
Q

wound site factors that affect healing

A

pressure (interferes w/ blood supply)
desiccation (too dry)
Maceration (too moist)- inc bac. growth
edema (disrupts normal o2 and blood flow to wound)
infection (energy is diverted to immune response, not wound healing)
necrosis (tissue slough and eschar)
* dictate the difference btw a chronic and acute wound

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21
Q

general factors that affect healing

A

circulation and oxygenation
nutritional status- presence of protein, hydration
addit. chronic illnesses- alter immunes response
wound chara- baseline condition
immunosuppression- ex. aids, or autoimmune reaction

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22
Q

wound assessment- inspection

A

inspection

edges, location, size, depth, surr. tissue, drainage, type of closure

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23
Q

wound assessment- exudate types

A

type
serous- watery
sanguineous- bloody
serosanguineous- watery and bloody

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24
Q

wound assessment- signs of complications

A

odor, pus (purulent), excessive heat, pain w/ palpation

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25
Q

wound assessment- tunneling

A

feel around wound edges

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26
Q

wound complications- infection

A 
edema, surr. color hot and painful 
erythema
drainage inc (maybe purulent)
wound edges could be seperated w/ dehiscence
inc WBC count
febrile temperature 100.5> 101
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27
Q

wound complications- hemorrhage

A

excessive bleeding at wound site

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28
Q

wound complications- dehiscence

A

skin pulls apart at suture line

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29
Q

wound complications- evisceration

A

tissue layer seperation

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30
Q

wound complications- fistula

A

opening created by infection

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31
Q

pressure ulcer factors

A 
immobility
chronic illnesses
aging skin
malnutrition
fecal, urinary incontin
altered lvl consciousness
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32
Q

pressure ulcer - stage 1

A

red and non-blanchable

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33
Q

pressure ulcer - stage 2

A

missing top layer of skin

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34
Q

pressure ulcer - stage 3

A

subcutaneous tissue visible

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35
Q

pressure ulcer - stage 4

A

bone and tendon visible

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36
Q

pressure ulcer - “unstageable”

A

ulcer w/ slough or eschar

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37
Q

pressure ulcer - “deep”

A

closed w/ skin intact

dark purple color

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38
Q

braden scale categories

A 
23 points possible
less than 16 = at risk
sensory perception
moisture
activity
mobility
nutrition
friction and shearing
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39
Q

wound dressings- purpose

A 
remove necrotic tissue and exudate
prevent and control infection
maintain moist environment
protect surrounding skin + wound from further injury
provide physical comfort
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40
Q

penrose drain

A

passive, no reservoir

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41
Q

JP, hemovac or wound vac drain

A

active

used neg pressure to pull out exudate

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42
Q

cold application effects

A

15 min at time
vasoconstriction
reduces spasms

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43
Q

heat application effects

A

vasodilation
inc cap perm
red. muscle tension
relieves pain

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44
Q

nursing v medical diagnosis

A

nursing- analyzes pat. response “risk for”

medical- actual pathophysiology

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45
Q

nursing diagnosis- pat response

A

how indivi responds to pot. health
cause or etiology of problem
resources for help

46
Q

diagnosis purpose-

A

rule out similar problems
determine risk factors
list suspected problems/ symptom patterns
identify resources for health promotion

47
Q

nursing responsibilites

A 
rec safety risks and address imm.
            try to control or prevent risks
id response (problems, signs and sympt)
anticipate pot. problems
prioritize immediate needs
48
Q

collaborative problems

A

use b/ nursing and physician-prescribed interventions

ex. pain

49
Q

validation

A

ask pat. more questions if symptoms don’t match subjective report

50
Q

data interpretation- 4 steps

A

rec. sig. data- compare to standards
rec. patterns (ex. pain, swelling, redness, exudate could indicate an infection)
id strengths and potential problems
reach conculsions (point where make final decision)

51
Q

types of nursing diagnosis

A

problem- focused (3 parts)
risk- (2 parts)
health promotion or “readiness for education”

52
Q

4 diagnosis componets

A

label
definition
defining charac
related factor

53
Q

validation of diagnosis

A

have pattern, accurate data, objective data and based on scientific knowledge
need have >50% confidence o/ get same result

54
Q

nursing diag benefits

A

indiv. pat. care
definition of nursing to legislators
funding evidence

55
Q

nursing diag limitations

A

pat could be misdiag

nursing practice could be restricted

56
Q

nursing diag. errors

A

making legally inadvisable statements
identifying a patient’s etiology when it cannot be changed
identifying environmental problems and not patient problems

57
Q

nursing diag. errors continued

A

revere clause
“imbal. nutr. related to insuf. funds in meal budget”
versus
“deficient knowledge related to alteration in diet”

inc. value judgements (“pat. is lazy”)
inc. medical diagnosis in nurse diag. statement
diag. with no evidence or data
faulty data analysis
non-specific or individualized diagnosis

58
Q

outcome id and planning- purpose

A

design PoC w/ pat.

to prevent, reduce or resolve problems

59
Q

outcome id and planning- goals

A

est. priorities
id and write expected pat. outcomes
use evidence-based interventions
communicate the PoC

60
Q

outcome id and planning- legal standards

A

the law
national practice standards
speciality professional organizations
accrediting bodies (the joint commission)
AHRQ- agency for healthcare research and quality
employer standards

61
Q

plan of care- allows nurse to

A 
indivi care maximizes outcome achievement
set priorities
comm w/ colleagues/ healthcare providers
promote continuity high-quality + cost effective care
coordinate care
evaluate response to care
create record for reimbursement
promote own professional dev
62
Q

outcome id and planning- clinical reasoning

A

know standards for care plan, interventions, and pat outcomes
keep big picture in mind (discharge goals) (how effects interventions and choices)
respect intuition
recg. personal bias
make sure research supports plan before id outcomes

63
Q

goal of patient care

A

keep pat and pat interests / preferences in mind

not going to do something they hate

64
Q

comprehensive planning- parts

A

initial
ongoing
discharge

65
Q

comprehensive planning- initial

A

dev. by nurse who records history
id e/ problem in prioritized nursing diag
id pat goals

66
Q

comprehensive planning- ongoing

A 
done by nurse who has contact w pat
manages risk factors and keeps plan up to date
states diag more clearly
dev new diag
makes outcomes more realistic
id nursing inteventions
67
Q

comprehensive planning- discharge

A

done by nurse w/ closest relationship
begins upon admission
uses teaching skills make sure pat is successful at home
(can incl family educ)

68
Q

nursing diag- problem statement- purpose

A

suggests pat goals/ outcomes

69
Q

nursing diag- etiology- purpose

A

suggests nursing interventions

70
Q

high priority interventions

A

impaired gas exchange
risk for powerlessness
act. intolerance (if not related to condition)

71
Q

medium priority interventions

A

nonthreatening

72
Q

low priority interventions

A

not related to specific health problem

73
Q

maslows hierarchy of human needs

A

physiologic needs-

safety, love + belonging, self esteem, self actualization

74
Q

categories of outcomes- cognitive

A

inc pat knowledge/ intellec beh

“why infection prevention is important”

75
Q

categories of outcomes- psychomotor

A

pat achieves new skills

76
Q

categories of outcomes- affective

A

changes values, beliefs and attitudes of pat

77
Q

categories of outcomes- clinical

A

desc expected status of health issues after treatment complete

78
Q

categories of outcomes- functions

A

ability compared to desired ADL’s

79
Q

categories of outcomes- quality of life

A

factors affecting enjoyment + goal achievement

80
Q

IOM’s 6 aims for quality of care

A 
safe- avoid injury
effective- avoid under and overuse
patient centered- respect values
timely
efficient- avoid waste
equitable- treat w/out bias
81
Q

errors writing outcomes

A

includ more than 1 manifestation in short-term outcomes
vagueness
use verbs that are non-measurable

82
Q

outcome parts- measureable

A 
subject- patient
verb
conditions
performance criteria
target time
smart goals (specific, measurable, achiev, relevant, timely)
83
Q

implementing-purpose

A

4th step of process

help pat achieve goals, prevent dis, and restore health

84
Q

alfaro’s rule

A

assess, reassess, revise and record

85
Q

types nursing interventions

A

direct v indirect
indivi v family v community
nurse initiated v provider initiated

86
Q

nurse initiated inteventions

A 
not need provider order
monitor health status
redu. risks
resolve and manage problem
assist w/ ADL
promote emotional and physical well-being
87
Q

physician initiated interventions

A

physician response to med diag.

care carried out by nurse under doc. orders

88
Q

collab. interventions

A

initiated by provider, carried out by nurse

89
Q

intervention dev- considerations

A

pat willingness to coop
dev age and psycho background
response to PoC and goal achievement progress

90
Q

implementation- components

A

carry out plan
cont. data collection (modify as needed)
document care

91
Q

implementation- process

A 
id pat need for assistance
promote self care and teaching
assist pat achieve goals
reassess/review
interventions need by evidence based
intervent. consist w/ all policies and procedures
actions are safe for pat and desirable
clarify questionable orders
organize resources
anticip unexpec outcomes
prevent of errors
92
Q

clinical checklist for care

A 
pat profile
family needs
priorit for care and schedule
pat main complaint
assist needed for ADL
current health status
93
Q

patient var. influence pat goals

A

dev. stage

psychosocial backgrnd

94
Q

nurse var. influence pat goals

A

resources
curr standards of care
research findings
ethical and legal guides to practice

95
Q

reasons for noncompl w/ interventions

A 
lack family supp
low value for outcomes
lack understanding abt beliefs
emotion/phys effects of trtmnt
inabil afford trtmnt
limited access trtmnt
96
Q

implementation- care/experience

A

supp family and pat
reasses pat to see if action is necessary
approach w/ care and compentency
modify interventions accord to need
dev. experience (more interve= greater poss for success)

97
Q

delegation-considerations

A

state laws
make sure person understands, is competent, has training
know what pat is at risk for
take reports from CNA and family for changing condition

98
Q

evaluating

A

purpose- allow pat achiev direct future intervention

final step nursing process

99
Q

evaluating- allows nurse to

A

measure pat achievem outcome
directs nurse intervent
id factors for achiev
modify plan if necess

100
Q

termination

A

when outcomes are achiev

101
Q

modification

A

if diff achiev outcomes

102
Q

continuation

A

if more time needed for outcome achiev

103
Q

eval- elements (5)

A 
id- eval criteria and standards
collect data- determ if standards are met
interpret findings
docum judgement
termin, continuing or modifiying plan
104
Q

eval- criteria

A

measurable qualit. that specify skills, or health status

ex. performance accept. lvl for state

105
Q

eval- standards

A

lvl perform expected by nurse

est. by auth

106
Q

var affecting outc. achiev

A

patient (ex refusal)
nurse
health care system (understaffing)

107
Q

statement eval- met

A

term PoC

108
Q

statement eval- partially met

A

continue w/ modification

make more realistic

109
Q

statement eval- not met

A

start over

110
Q

PoC revisions-

A

change interventions
adjust time
make more realisitic

111
Q

IOM’s 10 rules improve care

A 
care based on healthy relationship
customiz based on pat needs
pat controls care
pat education
evidence-based decisions
high safety
high transparency
anticip pat needs
coop w/ provider
112
Q

improving performance (4)

A

step 1- id problem
plan strategy
implement change
if outcomes not met, assess achievement

NRSG 225- Intro (5 decks)

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