Final Review Flashcards
Nursing Process
Assessment/Data Collection Nursing Diagnosis Planning goals/outcomes care/ interventions Implementation Evaluation
Nursing Process: Assessment
Collect data Review of the clinical record Interview Health history Functional assessment Physical exam Consultation Review of the literature
Subjective: History
Objective: Exam
DATA BASE
Subjective Findings
Objective Findings
Lab/Diagnostic Results
DIAGNOSTIC REASONING
Analyze data and draw conclusions. Formulate hypothesis (“hunch”). Develop “list”… Cluster data in groups Validate data
Nursing Process: Diagnosis
Interpret data Identify clusters of cues – compare clusters Make inferences Validate inferences Identify related factors Document the diagnosis
Clinical judgment about client’s response to “actual” or “potential” health state
TYPES OF NURSING DIAGNOSES
ACTUAL DIAGNOSES
RISK DIAGNOSES
WELLNESS DIAGNOSES
Nursing Process: Planning
Establish priorities
Identify interventions
Document the plan of care
Nursing Process:
Outcome Identification
Identify expected outcomes
Individualize to the person
Realistic and measurable
Include a time frame
Nursing Process:
Implementation
Review planned interventions Schedule and coordinate total health care Collaborate with other team members Supervise implementation of care plan Counsel person and significant others - teaching Involve person in health care plan Refer for continuing care Document care provided
Nursing Process:
Evaluation
Refer to expected “outcomes”
Evaluate individual’s condition and compare actual outcomes with expected outcomes
Identify reasons for failure to achieve “expected” outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care
Evidence Based Practice (EBP)
SYSTEMIC APPROACH TO PRACTICE
EMPHASIZES “BEST EVIDENCE”
(RESEARCH BASED EVIDENCE)
COMBINES “BEST EVIDENCE” WITH…
MEDICAL DIAGNOSES
NURSING DIAGNOSES
Nursing diagnoses
are clinical judgments about a person’s response to an actual or potential health state
Biomedical model
Health as absence of disease
Health and disease are opposite extremes on linear continuum
Disease is caused by specific agents or pathogens
A natural progression to health promotion and disease prevention rounds out our concept of health
Guidelines to prevention emphasize link between health and personal behavior
WELLNESS MODEL
Dynamic processes
Continually moving toward “wellness”
HOLISTIC MODEL
MIND, BODY, SPIRIT = ONE ENTITY
Each part affects the others
HEALTH PROMOTION/DISEASE PREVENTION MODEL
Health and behavior are connected and inter-related”
NURSING MODEL “MIXTURE”
HOLISTIC MODEL
HEALTH PROMOTION/DISEASE PREVENTION
INCLUDES CULTURE, VALUES, FAMILY, SOCIAL ROLES, SELF-CARE BEHAVIORS, ETC.
Data Bases - 4 Types
- Complete Data Base (complete history and physical examination)
- Episodic or Acute Problem-Centered Data Base (focused assessment)
- Follow-up Data Base (re-check)
- Emergency Data Base (emergency assessment)
What is Culture
Culture is composed of all verbal and behavioral systems that transmit meaning
Culture is learned
Culture is shared
Culture is the result of adaptation to the environment
Culture is universal
Culture is dynamic
Becoming Culturally Competent
Cultural Sensitive Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounter Cultural Desire
Cultural Assessment
Health Beliefs/Practices Religious Beliefs/Practices Language/Communication Family Structure Other Support Systems Dietary Practices/Nutrition Educational Level
Principles of setting priorities
- Airway problems
- Breathing problems
- Cardiac and circulation problems
- Vital sign concerns (high fever)
Guide for cultural care
Preparing:
- discover and understand your own heritage, cultural values, biases, and traditional health beliefs and practices.
- Aquire basic knowledge of cultural values and health/health beliefs and practices for patient groups that you serve
RESPECT
Internal factors
Internal factors are those particular to the examiner, what you bring to the interview.
- Liking Others
- Empathy
- The ability to listen
External Factors
Prepare the physical setting.
- Ensure privacy
- Refuse interruptions
- Dress
- Note taking
PURPOSE OF CLIENT/PATIENT INTERVIEW
Obtain a health history
Begin a relationship with the patient
Teaching and learning
One of the most important parts of health care process.
MEASURES TO RELIEVE ANXIETY AND CREATE CLIMATE OF TRUST
Behavior of interviewer important Non-judgmental attitude Establish verbal contract Emphasize therapeutic goals/purpose Confidential Concentrate on “what the patient is saying”
INTERVIEW COMPONENTS
INTRODUCTION
WORKING PHASE
Data gathering phase. Use of open and
closed ended questions.
CLOSURE
Responses of the interviewer
Facilitation- Encourage the patient to say more such as nodding, saying go-on, continue, mmmk uh-huh.
Silence- use after open ended questions
Reflection- repeating what the patient said so that it shows that you were listening.
Empathy- an empathetic response recognises a feeling and puts it into words.
Clarification- Use this when a patients word choice is ambiguous or confusing. Example, tell me what you mean by…
Confrontation- this shifts the interview from the patients perspective to yours. (confrontation, interpretation, explanation, and summary)
10 COMMON TRAPS
False reassurance Giving unwanted advise Using authority Using avoidance language Distancing Using professional jargon Using biased or leading questions Talking too much Interrupting Why questions
OTHER TRAPS
Changing the subject Giving a social instead of therapeutic response Overloading/underloading Jumping to conclusions Talking too fast
NONVERBAL SKILLS
Appearance Posture Gestures Facial Expression Eye Contact Voice Touch
SPECIAL NEEDS
Hearing-Impaired Acutely ill Influence of drugs or EtOH Personal questions Sexually aggressive Crying
What question should you always ask when Closing the interview?
Is there anything else that you would like to mention.
Question 1: Which of the following is a good example of a well-written chief complaint?
A. Patient complaining of chest pain for about 3 days that is worse with activity and relieved with rest.
B. Pain is a 10/10.
C. Patient complaining of chest pain. R/O MI.
D. Patient states “I don’t know what this pain is. This is the worst I have ever felt.”
D. Patient states “I don’t know what this pain is. This is the worst I have ever felt.”
Question 2: Which of the following statements by the patient would indicate a substance abuse problem?
“I have a glass of wine each day with dinner.”
“My wife keeps nagging me to cut down on drinking.”
“I love to have a few drinks around the holidays.”
“I have a few drinks on the weekend when my friends get together.”
“My wife keeps nagging me to cut down on drinking.”
NURSING HEALTH HISTORY
“A nursing health history is the systematic collection of subjective and objective data used to determine a client’s health status, functional status and coping status”
(Carpenito, 1992)
The Complete Health History
Biagraphical Data
Source of history
Reason for seeking care
Always use qutotes
History of Present illness
CLITAAA
Past Health
Childhood illnesses
Accidents Injuries
Chronic Illness
Hospitalizations
Operations
Obstetric History
Shots
Last Exam date
Allergies
Current Meds
Family History
Review of symptoms
Functional Assessment
Self esteem
Activity/Exercise
Sleep
Nutrition
Relationships
Spiritual Resouces
Coping/ Stress Management
Alcohol / Drugs / Violoence
Perception of HealthMental Status Assessment
ABCT
Appearance
Behavior
Cognitive Functions
Thought Processes
Levels of conciousness
- Alert- Awake redily aroused, oriented, fully aware, responds appropriately
- Lethargic- (somnolent)- not fully alert, drifts to sleep when not stimulated, can be aroused when name is called, drowsy
- Obtunded- transitional state between lethargic and stupor- sleeps most of the time difficult to arouse. Confused.
- Stupor- Semi coma- Spontaniously unconcious, responds only to vigorous shake or pain, has appropriate motor response, groans, mumbles.
- Coma- Completely unconcious- no response to pain, no purposeful movement
Delerium-
Acute confusional state- clouding of conciousness (dulled cognition, impaired alertness) in attentive, incoherent conversation, usually brought on by stress of hospital stay or meds and goes away
Broca’s Aphasia
Expressive aphasia. The person can understand language but cannot express himself using language.
Auditory and reading is intact.
Due to lesion in the anterior langage area called the motor speech cortex or Broca’s Area. (Frontal Lobe)
Wernicke’s Area
Receptive aphasia- The liguistic opposite of Broca’s aphasia. The person can hear and sounds and words but cannot relate them to any meaningful previous experiences. Speech is fluent, effortless, and well articulated.
Lesion is in the posterior language area called the association auditory cortex or Wernicke’s area.
Temporal lobe left side of brain
What is the difference between depression and anxiety?
Depression- sad gloomy, dejected.
Anxiety- Worried, uneasy, apprehensive from anticipation of danger whose source is unknown
Alcohol abuse at risk drinking-
men- more than 14 drinks a week or 4 drinks an occasion.
women- more than 7 drinks a week or 3 drinks an occasion
Disorders of Altered Mental Status (Organic)
Delirium – temporary (next slide)
Dementia - permanent (next slide)
Alcohol Intoxication
Alcohol/Controlled Substance Withdrawal
Alcohol
Most used and abused psychoactive drug
Alcohol is involved in 40% of 41,000 annual deaths due to traffic accidents
Emergency department visits
Four drinks per day associated with
increased rates of death in men from:
Cirrhosis
Cancers
Injuries
Women -_________drinks/day
at risk for Breast Cancer
2
About 8% of Americans aged 12 or older reported current illicit drug use in 2008
Marijuana - most common
Prescription pain medications/Benzodiazipines
Audit Test
- How often do you have a drink containing alcohol?
- How many drinks do you consume that have alcohol on a typical day when you are drinking.
- How often do you have 5 or more drinks on occasion?
Cage Questions
Cutdown
Annoyed
Guilty
Eye-opener
Abrasion
a wound caused by rubbing the skin or mucous membrane
Avulsion
The tearing away of a structure or part
Bruise
Superficial discoloration due to hemorrhage into the tissues from a broken blood vessel underneith the skin surface.
Contusion
A bruise; injury to the tissue without breaking the skin
Cut
Incision
Ecchymosis
A hemorragic spot or blotch larger than a petechia, in the skin or mucous membrane, forming a non elevated, rounded or regular, blue or purplish patch.
Hematoma-
A localized collection of extravasulated blood usually clotted in an organ, space, or tissue.
Hemorrhage
The escape of blood from a rupured vessel, which can be internal or external, in the skin or an organ.
Assessment techniques
IPPA
Inspection
Palpation
Percussion
Auscultation
Percussion sounds
Resonant- medium loud, low pitched
Ex- lung
Hyperresonant- Louder, lower pitched
Ex- emphysema lung or child lung
Tympany- Loud, high pitched
Ex- stomach, intestine, abdomin
Dull- soft, high pitched
Ex- liver, spleen
Flat- very soft, high pitched
Ex- Where no air is present,
muscles, bone or tumor
Auscultation
Never over shirt or gown
Diaphragm- for high pitched sounds
Bell- For low pitched sounds
General Survey
ABBM (objective)
Apearance
Behavior
Body Structure
Mobility`
BMI
Normal - 19-24
Overweight- 25-29
Obese- 30-39
Morbidly obese- greater than 40
Factors that contribute to Blood pressure
Vascular resistance
Elasticity of the arterial walls
Normal Range for Blood Pressure
128/80
Hypertension
140-90
