exam1 Flashcards
4 aspects of clinical judgement
noticing
interpreting
responding
reflections
what is critical thinking
a combination of reasoned thinking, openness to alternatives, ability to reflect, and desire to seek truth
EBP
most efficient. based around scientific evidence, clinical experience, and patient values
florence nightingale
founder of modern nursing. started the first nursing school
patricia benner
noves to expert nurse
noves
task oriented nurse. don’t see whole picture
advanced beginner
thinks more about what makes the most sense
competent nurse
recognize patterns
proficient nurse
looking more holistically
expert nurse
sees and fixes a problem before it becomes one
Marlowe hierarchy of needs from most to least
physiological
safety
love and belonging
esteem
self actualization
CRAAP acronym
currency
relevance
authority
accuracy
purpose
health
state of complete physical, mental, and social well being
5 stages of illness behavior
experience symptoms
sick role behaivor
seeking professional care
dependance on others
recovery
spirituality
a journey, subjective experiences.
religion
has beliefs and practices
best to measure intake
graduated cup
best to measure outtake
gradient cylinder
positive in fluid balance
input greater than output
negative in fluid balance
output greater than input
NPO
nothing per oral
I/o q hour
input and out take every hour
strict I/o
measure everything
enteral
directly to GI
CC
another word for milligrams
void
urine
EHR
electronic health record
measuring food
percentage as whole
how does infection spread
pathogen must exit reservoir
indirect contact
contact with fomite- contaminated object
common infection portal of entry
wounds, surgical sites, insertion sites of tubes and needles
systemic infection
pathogens invade blood or lymph
bacteremia
bacteria in blood
exogenous infection
pathogen acquired from healthcare enviroment
endogenous infection
pathogen arises from patients normal flora, with some treatment cause the microbe to multiply
stages of infection
incubation
prodrome
illness
decline
convalesence
primary defense
Normal flora of the body
skin
Respiratory tree
eyes
mouth
GI tract
Anus and urethra
secondary defense
Phagocytosis
Complement cascade
Inflammation
Fever
active immunity
body makes its own antibodies or T lymphocytes
passive immunity
when a person receives antibodies from someone else. like vaccine
bronchodilators
Relax the smooth muscles lining the airways.
can assessment be delegated
no
activities that dont need assessment
mobility, transfer, bathing, dressing, feeding, toileting, continence
diagnosing involves
critical thinking and logical reasoning
risk diagnosing
no signs or symptoms but pieces come together that patient could have it
prioritizing problems
top-bottom
transcendence (least), self actualization, aesthetic, cognitive, self-esteem, love and belonging, safety and security, physiological
when writing quality statement
avoid using medical diagnosis and treatments for etiology
be sure the etiology doesn’t restate the problem
be descriptive
outcome
specific observable measure, must include target time
goal
broad, nonspecific statement about desired result
direct care
counseling
observing
interactions
physical care
ADLs
teaching
indirect care
advocacy
delegating
evaluating
empathy
You understand peoples pain
sympathy
you feel bad for people, but you dont understand their pain
concrete
clear and confident
aphasia
unable to speak
are you able to tell the patients everything will be okay?
no
safety
basic human need for patients, us and other workers
how many patients die a year due to mistakes in care
161K
Factors affecting patient safety
lifestyle, cognition, developmental stage, balance, gait, mobility, ability to communicate, visual acuity, emotional health, safety awareness
never events
things that should never happen in the hospital due to protocols
whats the most common safety concern in healthcare
falls
Sentinel event
events that can lead to death or a lot of harm. Ex- medication error, delay in treatment
safety hazards for workers
workplace violence, disease, back injury, radiation, needlestick injury
improving safety in workplace
follow protocols, speak up, communicate, taking care of yourself, continuing caring, don’t assume
restraints
device or method use for restricting to help keep patient from hurting themselves. You must have an order for this. If they have one, monitor them every 2 hours.
why hourly rounding?
meet patients need instead of waiting for them to need. Also reduce call button times
scale for fall risk
morse
what to do if someone falls on your shift
document findings and look for injuries. Identify actions to prevent recurrence
moral distress
you know what the right thing to do is but you are unable to do it
ethical principles
autonomy, nonmalefinence, beneficence, fidelity, veracity, justice
autonomy
respecting the patients right to choose. Patient needs all the info to choose
nonmaleficence
do no harm. benefits need to outweigh
beneficence
doing the right thing
fidelity
keeping promises
veracity
telling the truth
justice
treat everyone equally, everyone gets equitable care for their case
nurse practice act is determined by
state board of nursing
patient bill of rights
States they will get care, they have the right to know there problems
PSDA (patient self determination act)
advanced directives. General term to indicate what a person wants or don’t want.. Ex- DNR, ADA (Allow natural death), living will, organ donation, health power of attorney
HIPPA
privacy and portability act
EMTALA ( emergency medical treatment and active labor act)
Patient that comes to ER must be triaged
ADA
American disability act. Specialized needs
Mandatory reporting
must report if we see experience or think could be present. Ex- abuse, infectious diseases
Patient confidentiality
only the people who need to know can know
Informed consent- got to have all the info
FALSE IMPRISONMENT
lead patient to believe they couldn’t do something
Assault and battery
assault- threat
battery- actually did something
Slander and libel
slender is spoken against the patient
libel is written against
AIDET
Acknowledge
Introduce- name role
Duration- brief idea of how long you’ll be in there
Explanation- briefly explain what your going to do and warn about pain
Thank you- thank for time and cooperation
SBAR
Situation- general overview. Ex- code, race, allergies, etc
Background- past history. Explain what has been done so far and how patient is responding
Assessment- quick head to toe summary
Recommendation- summarize plan of care, recommendations that will help, test results
subjective data
what patient says
objective data
what can be seen, only facts
initial assessment
when patient first comes in, gives a baseline
ongoing assessment
every other encounter with patient after first
comprehensive assessment
head to toe, look at everything
focused assessment
aimed at one specific area in general. What problem specifically is.
what must we check for in every single assessment
safety
what should we do after hearing info from a patient
validate it with them
clinical reasoning through use of
critical thinking
actual nursing diagnosis
has evidence for support
risk nursing diagnosis
a tendency for it to happen but hasn’t happened yet. No evidence yet
prioritizing patient needs
use ABC
1- airway, breathing
2. circulation
3. pain
why is shelter a physiological need
protects from elements like heat, and is important for body temp
critical thinking you need
education
reflection
experience
SMART
Specific
Measurable
Attainable- can they do this in this amount of time?
Relatable- does it relate to what’s going on with patient
timely - what’s the time goal?
STANDARDIZED nursing care plan
everyone has it
individualized care plan
fits need of specific patient
interventions
things we do to help
independent intervention
nurse can do it on there own. Need no order
dependent intervention
doctors order for intervention
interdependent intervention
working with other departments
implementation
putting intervention into affect
direct implementation
things I do
indirect implementation
things I was told to do
delegation
Right task
Right circumstance
Right person
Right direction/ communication
Right supervision
evaluation
Did intervention work?
Determines what comes next
-discontinue interventions
-continue interventions
-revise interventions
most forgotten phase
physiological needs
food, air, water, shelter, sleep, clothing, reproduction
safety needs
personal security, employment, resources, health, property
love and belonging
friendship, intimacy, family, sense of connection
esteem
respect, self esteem, status, recognition, strength, freedom
self actualization
desire to become the most one can be
Who can i use SCD on
bed bound patients who do not have blood clots or compartment syndrome
who to use a TED on
patients that are more mobile
biggest disadvantage to oxygen
fire hazzard
protective precautions
protecting the patient
Analytical reasoning
Interventions are based on likelihood of desired outcome.
Rely heavy on textbook info
Intuitive reasoning
Used by experienced nurses based on their in depth knowledge to intuitively grasp the info and know how to respond
Narrative reasoning
Helps the nurse to use info based on clients illness experience, coping ability and vision of future to develop client center plan of care
