Exam 2 Flashcards
nursing diag. format
problem, “related to”, etiology/cause, “as evidenced by”, defining characteristics
risk for nursing diag format
“risk for”, problem, “related to”, etiology/cause
*no as evidenced by
skin functions
protection body core temp regulation sensation vitamin d production immunological absorption elimination psychosocial
layers of the skin-deep to superficial
dermis, epidermis
skin integrity factors
circulation, hydration
age or medications ex. steroids
skin developmental factors-infant and elderly
inc chance for injury
skin thins and becomes less elastic and resilient w/ age
wound characteristics- intentional v unintentional
planned/purposeful or on accident
wound characteristics- open or closed
is the dermis visible?
ex. closed= hematoma (bleeding underneath skin)
wound characteristics- acute v chronic
chronic wounds take longer to heal
wound definition
integrity of skin or mucous mem. is broken/ no longer intact
skin in immunologic defense
first line
asepsis used for wound care
clean/ medical and surgical (sterile)
tissue trauma results in what changes
local and systemic
= change in vital signs
nutrients needed for wound healing
protein and adeq. blood supply
roll of exudate in wound healing
needs to be removed along w/ o/ fluid or foreign material
wound healing- first phase
hemostasis constriction followed by dilation immediately after tissue/skin injury platelets attract o/ cells exudate is formed= pain and swelling
wound healing- second phase
inflammatory
lasts 4-6 days
macrophages present, ingest debris and attract fibroblasts
acute inflammatory response = pain, heat, erythema and edema
fatigue is common*
wound healing- third phase
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
wound healing- fourth phase
maturation
begins 3-6 weeks after injury
collegen tissue dev.
wound remodeling
wound site factors that affect healing
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
general factors that affect healing
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
wound assessment- inspection
inspection
edges, location, size, depth, surr. tissue, drainage, type of closure
wound assessment- exudate types
type
serous- watery
sanguineous- bloody
serosanguineous- watery and bloody
wound assessment- signs of complications
odor, pus (purulent), excessive heat, pain w/ palpation
wound assessment- tunneling
feel around wound edges
wound complications- infection
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
wound complications- hemorrhage
excessive bleeding at wound site
wound complications- dehiscence
skin pulls apart at suture line
wound complications- evisceration
tissue layer seperation
wound complications- fistula
opening created by infection
pressure ulcer factors
immobility chronic illnesses aging skin malnutrition fecal, urinary incontin altered lvl consciousness
pressure ulcer - stage 1
red and non-blanchable
pressure ulcer - stage 2
missing top layer of skin
pressure ulcer - stage 3
subcutaneous tissue visible
pressure ulcer - stage 4
bone and tendon visible
pressure ulcer - “unstageable”
ulcer w/ slough or eschar
pressure ulcer - “deep”
closed w/ skin intact
dark purple color
braden scale categories
23 points possible less than 16 = at risk sensory perception moisture activity mobility nutrition friction and shearing
wound dressings- purpose
remove necrotic tissue and exudate prevent and control infection maintain moist environment protect surrounding skin + wound from further injury provide physical comfort
penrose drain
passive, no reservoir
JP, hemovac or wound vac drain
active
used neg pressure to pull out exudate
cold application effects
15 min at time
vasoconstriction
reduces spasms
heat application effects
vasodilation
inc cap perm
red. muscle tension
relieves pain
nursing v medical diagnosis
nursing- analyzes pat. response “risk for”
medical- actual pathophysiology
nursing diagnosis- pat response
how indivi responds to pot. health
cause or etiology of problem
resources for help
diagnosis purpose-
rule out similar problems
determine risk factors
list suspected problems/ symptom patterns
identify resources for health promotion
nursing responsibilites
rec safety risks and address imm.
try to control or prevent risks
id response (problems, signs and sympt)
anticipate pot. problems
prioritize immediate needscollaborative problems
use b/ nursing and physician-prescribed interventions
ex. pain
validation
ask pat. more questions if symptoms don’t match subjective report
data interpretation- 4 steps
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)
types of nursing diagnosis
problem- focused (3 parts)
risk- (2 parts)
health promotion or “readiness for education”
4 diagnosis componets
label
definition
defining charac
related factor
validation of diagnosis
have pattern, accurate data, objective data and based on scientific knowledge
need have >50% confidence o/ get same result
nursing diag benefits
indiv. pat. care
definition of nursing to legislators
funding evidence
nursing diag limitations
pat could be misdiag
nursing practice could be restricted
nursing diag. errors
making legally inadvisable statements
identifying a patient’s etiology when it cannot be changed
identifying environmental problems and not patient problems
nursing diag. errors continued
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
outcome id and planning- purpose
design PoC w/ pat.
to prevent, reduce or resolve problems
outcome id and planning- goals
est. priorities
id and write expected pat. outcomes
use evidence-based interventions
communicate the PoC
outcome id and planning- legal standards
the law
national practice standards
speciality professional organizations
accrediting bodies (the joint commission)
AHRQ- agency for healthcare research and quality
employer standards
plan of care- allows nurse to
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
outcome id and planning- clinical reasoning
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
goal of patient care
keep pat and pat interests / preferences in mind
not going to do something they hate
comprehensive planning- parts
initial
ongoing
discharge
comprehensive planning- initial
dev. by nurse who records history
id e/ problem in prioritized nursing diag
id pat goals
comprehensive planning- ongoing
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
comprehensive planning- discharge
done by nurse w/ closest relationship
begins upon admission
uses teaching skills make sure pat is successful at home
(can incl family educ)
nursing diag- problem statement- purpose
suggests pat goals/ outcomes
nursing diag- etiology- purpose
suggests nursing interventions
high priority interventions
impaired gas exchange
risk for powerlessness
act. intolerance (if not related to condition)
medium priority interventions
nonthreatening
low priority interventions
not related to specific health problem
maslows hierarchy of human needs
physiologic needs-
safety, love + belonging, self esteem, self actualization
categories of outcomes- cognitive
inc pat knowledge/ intellec beh
“why infection prevention is important”
categories of outcomes- psychomotor
pat achieves new skills
categories of outcomes- affective
changes values, beliefs and attitudes of pat
categories of outcomes- clinical
desc expected status of health issues after treatment complete
categories of outcomes- functions
ability compared to desired ADL’s
categories of outcomes- quality of life
factors affecting enjoyment + goal achievement
IOM’s 6 aims for quality of care
safe- avoid injury effective- avoid under and overuse patient centered- respect values timely efficient- avoid waste equitable- treat w/out bias
errors writing outcomes
includ more than 1 manifestation in short-term outcomes
vagueness
use verbs that are non-measurable
outcome parts- measureable
subject- patient verb conditions performance criteria target time smart goals (specific, measurable, achiev, relevant, timely)
implementing-purpose
4th step of process
help pat achieve goals, prevent dis, and restore health
alfaro’s rule
assess, reassess, revise and record
types nursing interventions
direct v indirect
indivi v family v community
nurse initiated v provider initiated
nurse initiated inteventions
not need provider order monitor health status redu. risks resolve and manage problem assist w/ ADL promote emotional and physical well-being
physician initiated interventions
physician response to med diag.
care carried out by nurse under doc. orders
collab. interventions
initiated by provider, carried out by nurse
intervention dev- considerations
pat willingness to coop
dev age and psycho background
response to PoC and goal achievement progress
implementation- components
carry out plan
cont. data collection (modify as needed)
document care
implementation- process
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
clinical checklist for care
pat profile family needs priorit for care and schedule pat main complaint assist needed for ADL current health status
patient var. influence pat goals
dev. stage
psychosocial backgrnd
nurse var. influence pat goals
resources
curr standards of care
research findings
ethical and legal guides to practice
reasons for noncompl w/ interventions
lack family supp low value for outcomes lack understanding abt beliefs emotion/phys effects of trtmnt inabil afford trtmnt limited access trtmnt
implementation- care/experience
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)
delegation-considerations
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
evaluating
purpose- allow pat achiev direct future intervention
final step nursing process
evaluating- allows nurse to
measure pat achievem outcome
directs nurse intervent
id factors for achiev
modify plan if necess
termination
when outcomes are achiev
modification
if diff achiev outcomes
continuation
if more time needed for outcome achiev
eval- elements (5)
id- eval criteria and standards collect data- determ if standards are met interpret findings docum judgement termin, continuing or modifiying plan
eval- criteria
measurable qualit. that specify skills, or health status
ex. performance accept. lvl for state
eval- standards
lvl perform expected by nurse
est. by auth
var affecting outc. achiev
patient (ex refusal)
nurse
health care system (understaffing)
statement eval- met
term PoC
statement eval- partially met
continue w/ modification
make more realistic
statement eval- not met
start over
PoC revisions-
change interventions
adjust time
make more realisitic
IOM’s 10 rules improve care
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
improving performance (4)
step 1- id problem
plan strategy
implement change
if outcomes not met, assess achievement
