Exam 3 Flashcards
Components of the nursing process
Assessment, diagnosis, planning, implementation, evaluation, outcome
assessment
collection of objective and subjective data
diagnosis
determine priority problem
planning
set SMART goals for positive outcomes
implementation
take action
Evaluation
evaluate effectiveness
goal of outcome identification and planning
establish priorities (what kills pt first), identify + write expected outcomes, select evidence based nursing outcomes, communicate care plan
IOM 6 aims to be met by health care systems
safe: avoid injury, effective: avoiding overuse and underuse, patient-centered: responding to patient preferences needs and values, timely: reducing waits and delays, Efficient: avoiding waste, equitable: providing care that does not vary in quality to all recipients
formal care plan allows nurse to
individualize care that maximizes outcome achievement, set priorities, facilitate communication, promote continuity of high-quality cost-effective care, coordinate care, evaluate patient response to nursing care, create record used for evaluation, research, reimbursement, and legal reasons
elements of comprehensive panning
initial: priority plan for the patient (developed by nurse who performs nursing history and P.A.; develops appropriate goals for pt), ongoing: continues throughout hospital care plan of care begins to change and adapt, discharge: what we do when patients leave (begins on admission)
outcome
SMART: specific, measurable, attainable, realistic, time bound
long-term outcome
require longer period to be achieved and may be used as discharge goals
short-term outcome
may be accomplished in specific period of time
categories of outcomes
cognitive, psychomotor, affective, clinical, functional, quality-of-life
cognitive outcome
describes increases in patient knowledge or intellectual behaviors
psychomotor outcome
describes patients achievement of new skills
affective outcome
describes changes in patients values, beliefs, and attitudes
clinical outcome
describe expected status of health issues at certain points in time after treatment is complete; address whether problems are resolved or to what degree they improved
functional outcome
describe persons ability to function in relation to desired usual activities
quality-of-life outcome
focus on key factors that affect someone’s ability to enjoy life and achieve personal goals
types of nursing intervetions
nurse initiated, physician initiated, collaborative
nurse initiated interventions
actions performed by nurse without physicians order (hygiene, BGL, ambulating)
physician initiated interventions
actions initiated by physician in response to medical diagnosis but carried out by nurse under doctor’s orders (fluid bolus, med admin)
collaborative intervention
treatments initiated by other providers and carried out by a nurse (nutrition and nurse collab to determine if pt is aspirating)
procedure
set of how-to action steps
standard of care
description of acceptable level of patient care
algorithm
set of steps used to make a decision
clinical practice guideline
statement outlining appropriate practice for clinical condition or procedure
institutional plans of care
computerized, concept map, change of shift reports, multidisciplinary (collaborative), student
how to assign priority
Maslows hierarchy of needs, ABC’s, nursing process, safety + risk reduction, least restrictive/least invasive, Acute vs. chronic/stable vs. unstable/urgent vs. non-urgent
Maslow’s hierarchy of needs
basic needs at base to psychological needs in middle, to self-fulfillment at top; needs at bottom must be met first
basic needs maslow
physiological (food, water, warmth, rest) then safety (security and safety)
psychological needs
belongingness and love needs (intimate relationships, friends) then esteem needs (prstige an feeling of accomplishment)
self-fulfillment needs
self actualization (achieving ones full potential including creative activities
ABCDE
airway, breathing, circulation, disability (neurological status, response to stimuli, level of orientation), exposure (check client head to toe for concerning signs
the 6 cognitive skills
recognize cues (assessment), analyze cues (diagnosis/analysis), prioritize hypotheses (diagnosis/analysis), generate solutions (planning), take action (implementation), evaluate outcomes (evaluation)
nursing process assessment
subjective data, objective data, then assessment type
nursing process analyze
identify assessment findings, include additional info (labs or vitals)
prioritize hypothesis
evaluate and ranking according to priority: urgency, risk, time, difficulty, likelihood; include diagnostic testing results and nursing note
generate solutions
summarize clinical info up to this point and most likely cause of clinical presentation
take action
include list of orders from healthcare provider, implement solution that addresses highest priority
evaluate outcomes
outline interventions that were taken to care for client; focus on efficacy of intervention
Documentation includes
data related to assessing, diagnosing/analyzing, planning, implementing, and evaluating (nursing processes); facilitates quality and evidence based patient care; serves as financial and legal record; helps clinical research; supports decision analysis
characteristic of effective documentation
consistent with professional and agency standards, complete, accurate, concise, factual, organized, timely, legally prudent, confidential
characteristics of effective documentation content
reflect nursing process and nursing responsibilities, record objective findings/observations, avoid use of subjective words (good, sufficient), avoid copying and pasting, b professional
when to document
upon admission, transfer to new unit, discharge, assessment or procedure performed, receiving pt post-op/post-procedure, change in pt status, communicating with health care provider regarding critical pt information (abnormal labs)
pt have right to
see and copy health records, update health records, get list of disclosures, request restriction on certain uses, choose how to receive health info
RN receiving verbal orders
must come from healthcare provider directly, record orders in pt medical record with initials, read back, date and time orders issues, record verbal order and HCP name followed by RN initials; limited to urgent situations
what to document
pt is always the focus, support subjective data with objective facts, report facts, report new or changed info/observations, avoid personal opinions/biased statements, chart problems with the actions taken, chart pt response and reaction
SOAPIER
subjective, objective, assessment, plan, interventions, evaluations, response
PIE charting
problem, intervention, evaluation
Focus charting
patient and patient concern, data, action, response
if not charted than…
not done
charting exceptions
shorthand for documenting normal findings; document significant findings or exceptions; goo because requires less time but important findings may be left out
when to use handoff reports
shift change, unit change, patient transfer (hospital to rehab)
important info for new nurse to obtain coming onto shift
Medical HX, chief complaint, head to toe exam, meds on and meds due, feeding, fall risk, discharge, allergies, labs, LOC
ISBARR report nurse to nurse
introduction, situation, background, assessment, recommendation, repeat back
SBAR
Situation, background, assessment, recommendation
IPASS report nurse to nurse
Illness severity, patient summary, action, situation awareness and cognitive planning, synthesis
Incident report
used by facilities to document unexpected eventa that resulted or could have resulted in harm, file whenever e=unexpected event occur, used for risk management and QI; senitnel and never events (sentinel = occurs in death, never =
medical error never should have occurred)
shift to shift RN report
involves oncoming RN, outgoing RN, pt, and family; records, goals, and orders reviewed
SBAR purpose
direct and focused, thorough, logical, used to coordinate pt care, ensure safe med admin., completely conduct handoff/transfers, report change in pt status
Situation (SBAR)
frame of reference (your name, status, unit & pt name, room number) & whats going on (state in one sentence: problem, when it happened/started, and severity)
Background (SBAR)
what led to current situation, include pertinent pt info
pertinent pt info for SBAR
admitting diagnosis and date of admission, current meds/allergies/IV fluids, most recent vitals, current labs (compared to previous), code status
Assessment (SBAR)
what you think is happening using best judgement
Recommendation (SBAR)
course of action you expect to take; what you suggest for the patient (can take time to become comfortable)
functions of respiratory system
pulmonary ventilation (inspiration + exhalation), ventilation-respiration (gas exchange), perfusion (oxygenated blood pass through tissues),
upper airway structures
nose, pharynx, larynx, epiglottis; warm, filter, humidify air
lower airway structures
trachea, L + R mainstem bronchi, segmental bronchi, terminal bronchioles
lower airway function
conduction of air, clearance and production of surfactant
mucus purpose
traps cells, particles, and debris to keep underlying tissue from becoming irritates; need adequate water to keep mucus thin
cilia purpose
hair-like projections that propel trapped material toward upper airway to be removed by coughing
surfactant purpose
reduce surface tension, preventing alveolar collapse
thoracic structure landmarks
sternal notch, manubrium, manubriosternal junction/sternal angle/angle of louis, body of sternum, costochondral junctions, xiphoid process, costal angle
lowest point posteriorly on exhalation and inhalation
T10 and T12 respectively
anterior lines of reference
anterior axillary, midclavicular, midsternal
posterior lines of reference
scapular, vertebral
lateral lines of reference
anterior, mid, and posterior axillary lines
purpose of breathing
supply oxygen, remove CO2, maintain acid-base balance, heat exchange
breathing control
hypercapnia, hypoxemia, pH
process of ventilation
diaphragm contracts and descends, external intercostal muscles contract (lift ribs up and out), sternum is pushed forward, increased lung volume and decreased intrapulmonic pressure allows for air to move from greater pressure in, relax/recoil of these structures allow for expiration
developmental considerations
infant and chidren, aging adult
infant and children developmental considerations (respiratory)
llergy, colds, wheezing, asthma, childproofing home, smokers, pollution
aging adult developmental considerations (respiratory)
dyspnea on exertion, activity level, stress, chronic diseases (renal failure, anemia), loss of elasticity, weaker immune system, medications (opioid decrease RR)
respiratory history components
cough, SOB, chest pain with breathing, past history of respiratory illness, smoking history, environmental exposure, self-care
signs of respiratory dysfunction
cough, wheeze, sputum production, SOB (dyspnea)
Respiratory assessment
Inspection, palpation, percussion, auscultation
Respiratory P.E.
inspection: rate, pattern effort (pursed lip? distressed? labored?), thoracic cage shape, use of accessory muscles, posture, skin/nails, level of consciousness, ability to speak, any chest deformities, AP ratio (1:2), barrel chest, spine deformities
clubbed fingers sign of
chronic hypoxia
respiratory patterns
normal, tachypnea, bradypnea, hyperventilation, hypoventilation, cheyne-stokes, biot’s, apnea (>20 seconds)
pectus excavatum
inward depression of sternum
pectus carinatum
outward protrusion of sternum; pigeon chest
kyphosis
hunch-back (upper T-spine area)
barrel chest
AP diameter (transverse diameter) ratio 1:1; common in emphysema d/t air trapping; normal in infants
palpation (respiratory)
note skin temp., assess expansion (should be symmetrical), note masses/edema/tenderness, palpate PMI, palpate extremities, assess pulse and cap refill
percussion (respiratory0
no used frequently; done by advanced practice HCP
auscultation (respiration)
begin on back using diaphragm; Z-pattern comparing sides; note whether sounds are bronchial, bronchovesicular, or vesicular depending on location; make note of unexpected breath sounds
breath sounds
bronchial, bronchovesicular, vesicular
bronchial breath sounds
heard over trachea; high-pitched; inspiration slightly shorter than expiration
bronchovesicular
heard over main bronchi; medium pitch; inspiration = exhalation
vesicular
heard over peripheral lung fields; low pitched; inspiration longer than expiration
hearing decrease in intensity
often first sign of disease
crackle lung sounds
high pitched, discontinuous, popping sound, heard on inspiration; does not clear with coughing (heard with CHF and pneumonia); air passing through fluid in small airways
crackle sound interventions
fluid restriction, diuretics; does not clear with coughing
wheeze lung sounds
high pitched, continuous, musical, squeaking, heard during inspiration and expiration; passes through narrow constricted airway
rhonchi lung sound
low pitched, continuous, snoring or rumbling, heard during inspiration and expiration, sounds like “junk in lungs”; can clear with coughing and deep breaths
stridor lung sounds
high pitched crowning sound, heard on inspiration and expiration, upper airway obstruction and croup
rhyme to remember
rhonchi in the bronchi; rales in the tails
peak flow monitoring
measures peak expiratory flow rate in L/min (PEFR); reflects changes in size of airways; aka point of highest flow during expiration
green zone PEFR
medication is working; go ahead with normal activities
yellow zone PEFR
use caution in your activities; refer to treatment plan for actions to be taken
red zone PEFR
medical alert; get immediate medical attention
oxygen administration
use lowest concentration to maintain O2 >90%; target SpO2 88-92%for COPD; use humidified O2 for high flow
Nasal Cannula
24-44% oxygen; 1-6L; nasal prongs point down
Rules of 4s Low flow NC
1L = 24%; 2L = 28%; 3L = 32%; 4L = 36%, 5L = 40%; 6L = 44%
Simple mask
40-60%; 5-8L (low flow); assess for claustrophobia; put in order for NC during meal time
venturi mask
24-40%; delivers most precise concentration of O2; color coded
reservoir masks
partial rebreather mask and nonrebreather mask
partial rebreather mask
50-75%; 8-11L/min; air in reservoir mixes with 100% O2 for next inhalation; conserves O2 in this manner
nonrebreather mask
80-95%; 10-15L/min; one-way valves prevent pt from rebreathing exhaled air; reservoir filled with 100% O2 that enters mask on inhalation
safety considerations for oxygen
no smoking. check flow rate regularly (part of gen. survey), check water level in reservoir for humidified oxygen
nebulizer treatments
disperses fine particles of liquid medication into resp. tract; meds such as bronchodilator continued treatment until med is gone (~15min)
nursing considerations after nebulizer treatment
reassess lung sounds, O2 sat., resp. after treatment
Metered dose inhalers (MDIs)
uses controlled dose of med with each compression (bronchodilators, mucolytic, corticosteroids); rinse mouth out after to prevent thrush (oral candidiasis); always use spacer (aerochamber)
MDI common mistakes
failure to shake cannister, holding upside down, inhaling through nose, inhaling too rapidly, stopping inhalation too early, failing to hold breath, two sprays in one breath
dry powder inhalers (DPI)
flow of med activated by pt breath; pt must be able to take powerful inspiration for adequate drug inhalation; some DPI require loading dose
respiratory pearls
hydration to maintain fluidity of secretions (thick secretions = airway resistance); drink 1.0-2.9L/day unless CHF; high fowlers to increase respiratory excursion (prevents pooling of mucus), progressive ambulation (promotes peristalsis, increases circulation, gravity to expand thorax)
leg exercises (respiratory)
prevent venous stasis and thrombus formation via contraction of quadriceps and gastrocnemius
deep breathing
used to overcome hypoventilation; in through nose out through mouth; 3-4 times per day/ 10 breaths per set; used post-operatively or for bedrest pt
pursed lip breathing
prolong exhalation creating smaller opening for air movement; helps with feelings of dyspnea or panic
diaphragmatic breathing
reduces RR, increases alveolar ventilation, promotes effective expiration; one hand on abdomen one hand on middle of chest; breathe in via abdomen breathe out via pursed lip while contracting abs (do for1 minute then rest for 2); helpful for COPD pt
incentive spirometry
visual reinforcement for deep breathing; helps to breathe slow and deeply (promotes optimal gas exchange); measures maximal inhalation in mL; used post-operatively; 10x per hour is goal
respiratory interventions
coughing and deep breathing; coughing cleanses airway; use pillow to splint chest or cover abdominal incisions
chest physiotherapy
mobilizes/loosens mucus, includes percussion, no used in peds/pneumonia/COPD/ post-op pt, common inf CF pt., performed by RT
sputum culture
suctioned or coughed up; used for gram stain and to find culture + sensitivity
nursing interventions to promote adequate respiratory function
teaching of pollution-free envir., promote optimal function, promote comfort, promote adequate hydration/humidification, encourage activity, promote proper breathing, promote/control coughing, meet oxygen needs with O2 and meds
factors that affect bowel elimination
diet/fluid intake, body position (bed rest), activity and exercise (improves GI motility/muscle tone
recommended fluid intake
2000+ mL/day
recommended fiber intake
25-38g per day; from whole grains, bran, beans, fruits, vegetables
defecation
emptying of large intestine stimulated by distension of rectum by fecal mass (parasympathetic stimulation)
defecation controlled by
medulla, spinal cord, PNS stimulates internal anal sphincter relaxation, Somatic NS causes voluntary relaxation of external sphincter
GI coditions
constipation, diarrhea, bowel/fecal incontinence
constipation
has to occur 3x within one week; can be caused by medication (narcotic and iron)
diarrhea
high water and electrolyte content; 3x in one day; caused by hyperthyroidism, meds, infection, malabsorption, diabetes
causes of bowel incontinence
brain injury, spinal cord injury, disorientation/confusion (causes inhibition of defecation reflex)
fecal impaction
seepage or incontinence of liquid stool with no signs of normal feces; flatulence still occurs; treatment of oil retention enemas and digital impaction
GI signs/symptoms
flatulence, distention, melena, clay/white stool
flatulence
accumulation of gas in GI tract from swallowed air, undigested food, bacteria breakdown
distension
when gas accumulates
melena
dark/black stools (upper GI bleed)
clay/white stool
lack of bile; difficulty with digestion of fat
colorectal screening
stool guaiac test (test for peroxidase), colonoscopy (visualize large intestine), colorguard
meds that alter bowel issues
laxatives/cathartics, antibiotics, narcotics
collecting stool specimens protocol
void first to avoid contamination, defecate into container not toilet, no toilet paper or soap, 1 inch of solid stool or 30mL of liquid
stool culture tests for
ova/parasites and needs to be transported warm or bugs die
hemoccult testing
guaiac test, fecal immunochemical test
guaiac test
for blood not visible, blue = positive; false positives d/t NSAIDs steroids iron
fecal immunochemical test
uses antibodies against Hgb to detect blood, positive for bleeding in lower GI, perks are no drug or dietary restrictions
enema
clears bowel; cleansing evacuates feces vs. retention stays in bowel for longer to lubricate mucosa, relieve gas, provide meds absorbed in mucosa
enema mechanism of action
distends bowel, irritates bowel mucosa, increases peristalsis, lubes stool and mucosa
contraindications of enema
thrombocytopenia/leukopenia, immunocompromised, fistula, bowel obstruction, paralytic ileus
large enemaa
tap water, saline, soap suds (irritates mucosa to stimulate peristalsis; 500-1L and retain for ~15 min
small volume enemas
70-130mL, distends bowel, retain for 5-10 min
retention enemas
30-60 min, 150-200 mL, lubricates stool and intestinal mucosa
enema care considerations
pt on left side, flush tubing of air, insert 4 inches and towards umbilicus, administer slow with gravity at room temp, assess for cramping and slow down if present
nutrition developmental considerations
growth, infancy, adolescence, pregnancy, activity, age-related changes in metabolism and body composition, birth sex, state of health, alcohol use disorder, medications, megadoses of nutrient supplements
factors that influence food choices
social determinants of health, religion, meaning of food, culture
output
urine should be about 0.5-1.5mL/kg/hour; 30mL per hour
insensible loss
cannot be seen or measured (respiration)
fluid output
should equal input; 1500 as urine, 600 from skin, 400 from lung, 100 in feces; total 2600mL
skin trgor
assesses fluid balance; sternum and under clavicle
documenting I/O
time and amount, add totals every shift, compare 24 hour totals
fluid restriction
ice chips as allowed, offer fluids 1-2 hour intervals between meals
modified consistency diets
liquid (clear, full liquid), mechanically altered (pureed is good for dysphagia, mechanical soft)
pt with dysphagia feeding
sit pt upright (high fowlers) at 90 degrees, chin tucked when swallowing, small frequent meals, signs of choking are coughing and cyanosis
diet progression
liquid: clear to full, soft, regular
therapeutic diets types
fat-restricted (atherosclerosis/gallstones), sodium restricted (500-3000mg/day for heart, renal, liver disease), high-residue/high-fiber (diverticulitis, IBS, constipation), diabetic diet/consistent carbs, gluten free (celiac disease), renal diet (low potassium, low protein, sodium restriction for CKD)
nutrition assessment
part of gen. survey that assesses gen appearance, interactions, energy
malnourishment assessment
dry brittle hair, dry scaly pallor skin (poor turgor), dry mucous membranes, pail brittle spoon shaped nails (koilonychia), interactions, vitality (sleep pattern, fatigue, decreased activity)
assessing dietary intake
24 hour recall, food diaries/calorie count, food frequency records, diet history
mini nutritional assessment (MNA)
gold standard; decline in intake and why, presence of involuntary weight loss?, mobility, psychological stress?, neuropsychological disorder?, BMI; max is 14 points: 12-14 normal, 8-11 at risk, 0-7 malnourished
nutritional screening
DETERMINE
DETERMINE
disease, eating poorly, tooth loss/mouth pain, economic hardship, reduced social contact, multiple medicines, involuntary weight loss, needs assistance in self-care, elder (>80)
BMI
<18.5 - underweight, 18.5-24.9 - normal, 25-29.9 - overweight, 30-34.9 obese I, 35-39.9 - overweight II, >40 extreme obesity
weight loss
unexplained is indicative of malnutrition (generally >5% in 6 moths)
enteral feeding
tube feeding: NG tube or nasointestinal tube
structures of urinary tract
kidneys, ureters, bladder, urethra (women 1.6in and men 8in)
micturition
act of voiding; pressure stretches detrusor muscle in bladder at about 150-250mL; urination initiated and causes detrusor muscle to contract and internal muscle sphincter relaxes then perineal and external sphincter relax; micturition center in pons
micturition nervous system control
PNS innervates from sacrum to promote urination, SNS from thoracic spine inhibits urination
frequency f urination
3-4 hours
factors affecting urination
food/fluid intake: EtOH diuretic effect d/t inhibition of ADH, high in Na less urine formed; activity/muscle tone: immobile causes decreased bladder/sphincter tone (poor urinary control and stasis) regular exercise is optimal for urine production and elimination; pathological conditions (UTI, HTN, PKD, diabetes); medications (diuretics, cholinergic meds stim. urination)
anuria
24 hr urine output less than 50mL
dysuria
painful or difficult urination
frequency
increased incidence of voiding
glycosuria
presence of glucose in urine
nocturia
awakening at night to urinate
oliguria
24 hr urine outpu less than 400mL
polyuria
excessive output of urine
proteinuria
protein in urine
pyuria
pus in urine
urgency
strong desire to void
urinary incontinence
involuntary loss of urine
ketonuria
ketones in urine
heistancy
involuntary delay in initiating uringation
hematuria
blood in urine
obstruction of urine flow
calculi, BPH, patency of indwelling catheter (is it blocked)
altered urinary output
UTI, causes of decreased muscle tone or chronic constipation, incontinence
UTI causes
CAUTI
UTI
can affect upper tract (kidneys/ureters-pyelonephritis or lower tract bladder/urethra-cystitis)
UTI symptoms
pain/burning, frequent urination, hematuria, pressure/cramping
stress incontinence
involuntary loss of urine caused by increase in intraabdominal pressure and weak perineal/abdominal muscle tone (laugh, cough, sneeze, exercise, heavy lifting)
stress incontinence causes, risk factors, treatment
caused by urethral external sphincter dysfunction, risk factors are poor muscle tone, treatment are pelvic floor exercises (kegel)
urge incontinence
loss of urine from time pt feels urge to urinate to time it takes to get to bathroom
urge incontinence cause, risk factor, treatment
cause: involuntary bladder contractions (bladder spasms) and decreased capacity, risk: UTI, meds, bladder irritants, over distended bladder, treatment- prompted voiding and q2 hours
managing incontinence
skin care (perineal care, skin barriers), pads, briefs
urinary assessment
inspection, palpation, percussion
urinary assessment palpate
bladder location and size; palpate gently and lightly; non-distended bladder is not palpable
urinary assessment palpation
can indicate if bladder is distended
urinary assessment inspection
urethral meatus if needed, empty bladder below pubic symphysis, lower abdominal wall swelling?, skin integrity, hydration status, examination of urine, bladder scan for fullness
alternative to indwelling urinary catheter
pure wick, condom catheter
collection bags
hanging bag, nelly bag, bag with urimeter, leg bag
indwelling catheter care
prevent pulling with tape, leg band, anchor but allow leg movement, ensure drainage to prevent hydronephrosis, urine assessment of tubing not bag d/t stasis changes
urine collection guidelines
avoid contamination with feces or tissue, store in fridge, note meses, minimum of 10mL in urinalysis, minimum of 3mL in culture
routine urinalysis
first morning void preferred, collect from bed pan, hat, condom cath, refrigerate immediately, tested with reagent sticks
clean catch specimen
used for culture and sensitivity, can be used for UA, if used for microbial testing send to lab immediately while warm; dont touch inside of cap
24 hour urine collection
initiate at specific time, discard first void, include last void, do not miss other urine or have to restart; do not use preservative but refrigerate or on ice
