Fundamentals Exam 3 Flashcards
A systematic, client centered, method of providing nursing care. It provides a framework for planning and implementing nursing care.
A dynamic, continuous process, involving scientific reasoning
Used to identify, diagnose and treat human responses to health and illness
Promotes individualized nursing care
Allows you to be organized and conduct practice in a systematic way.
The nursing process
What are the 4 purposes of the nursing process
To identify client’s health status
To identify actual or potential health care problems or needs
To establish plans to meet the identified needs
To deliver specific nursing interventions to meet the needs
What are the 5 phases of the nursing process
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
The process of gathering, verifying and communicating data about a client. Data is gathered from a variety of sources and is the basis for actions and decisions.
Phase 1- Assessment
Begins upon admission-becomes the database
Is a continual action throughout each phase of the nursing process
Data collection (part of assessment)
Data collection involves what 4 activities
Collect data
Organize the data
Validate the data
Document data
3 methods of collecting data
- Observation
- Interview
a. Formal
b. Informal - Examination
Data is classified as either ____ or ____ data
Objective or subjective
- Factual data observed by the nurse.
- No conclusions or interpretations are made.
Examples:
B/P 100/62
Voided 200cc dark amber colored urine
Objective data
- Information given verbally by the client
- Captures the client’s point of view.
Examples:
“I itch all over.”
“My stomach aches.”
“I’m afraid of going to surgery tomorrow.”
Subjective data
What are the 2 sources of data?
Primary (the patient)
Secondary (everyone else)
Groups of related pieces of data. Grouping like we did in our first column of our care plan with mobility and skin
Data clustering
A statement that describes the client’s actual, potential or wellness human response to a health problem that the nurse is competent and licensed to treat.
Identifies health problems and provide direction for nursing care.
Places emphasis on the nurse’s independent practice.
Phase 2- Nursing diagnosis
A client problem that is present at the time of the nursing assessment.
Alteration in comfort
Ineffective breathing pattern
Impaired skin integrity
Actual nursing diagnosis (3 part statement)
Problem does not exist, but the presence of risk factors indicates a problem is likely to develop without intervention.
Risk for injury
Risk for impaired skin integrity
Risk nursing diagnosis (2 part statement)
Describes human responses to levels of wellness that have a potential for enhancement
Readiness for enhanced spiritual well being
Readiness for enhanced family coping
Wellness nursing diagnosis (1 part statement)
Evidence about a health problem is incomplete or unclear – requires more data to support or refute
Possible social isolation related to unknown etiology
Possible nursing diagnosis
The 4 types of nursing diagnosis
Possible
Wellness
Risk
Actual
Components of a nursing diagnosis statement
Statement of the problem
Etiology
Defining characteristics or the cluster of signs and symptoms (in the three part statement only)
A two part nursing diagnosis statement usually contains the words ____ ___
“related to”
Ex: risk for injury (problem) related to decreased visual acuity and decreased mobility (etiology).
This is an example of what statement?
Activity intolerance related to bedrest as evidenced by exertional dyspnea and verbal report of fatigue and weakness
Constipation related to decreased mobility and decreased fluid intake as evidenced by no BM for 3 days
3 part nursing diagnosis statement
The first part of the nursing diagnosis statement comes from the __________
- These are called “ Diagnostic Labels”
- This is a listing of the problems
- You have to add the etiology that is specific for your client.
NANDA list
The nursing diagnosis is NOT a medical diagnosis – so avoid using ______
A medical diagnosis as part of the etiology in the nursing diagnosis statement.
*Example: Activity intolerance related to congestive heart failure
The phase of the nursing process in which you develop a plan of care and determine how you are going to solve, lessen or minimize the effects of the client’s problems.
Phase 3- Planning
What are the 4 steps in the planning phase of the nursing diagnosis
**study these aside in greater detail
- Setting priorities
- Writing goals and outcome criteria
- Planning nursing interventions (derived f/the etiology)
- Writing the care plan
Phase 4 of the nursing process
Implementation
What are the 5 steps of implementation?
- Reassessing the client
- Reviewing and revising the existing nursing care plan
- Organizing resources and care delivery
- Anticipating and preventing complications
- Implementing nursing interventions
The phase of the nursing process when the planned, ongoing, purposeful activity in which clients and health care personnel determine:
- client’s progress toward achievement of goals
- the effectiveness of the nursing care plan
In this step of the nursing process, the nurse measures the client’s response to nursing interventions and the client’s progress toward achieving goals.
Phase 5- Evaluation
a discipline specific, reflective reasoning process that guides a nurse in generating, implementing and evaluating approaches for dealing with client care and professional concerns.
Critical thinking
Institutional care plans that become part of the medical record
Kardex care plans
standardized care plans for each nursing diagnosis that are individualized for the client by the nurse
Computerized care plans
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation
Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care
Student care plans
Staff from all disciplines develop integrated care plans
Critical pathways care plan?
Provide a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions
Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help you make better clinical decisions in planning care
Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information
Concept maps
pre-established guides for nursing care.
Standardized care plans
Laws work within nursing in what 4 ways
Providing a framework which nursing actions are legal
Differentiates nursing from other health professionals
Determines independent nursing actions
Makes nurses accountable for their actions
Legally defines & describes the scope of nursing practice
Distinguishes between nursing and medical practice
Set by every state
Specifies educational requirements for licensure
Recognizes associate, diploma, & baccalaureate
Regulates Nursing Schools
Sets standards in clinical facilities for faculty
Approves curriculum
The State Board of Nursing oversees this function
Nurse practice act
Regulates who will practice nursing
State Board of Nursing licenses nurses in the state where they practice
Mandatory ~ must have license to practice
Specifies requirements to obtain and renew license (Can also revoke license)
Gives the NCLEX exam
Some states have a multi-state licensure
Continuing education
Nurse practice act
Establishes the State Board of Nursing Responsibilities Implementing licensure laws Regulates schools of nursing Conducts license revocation hearings
Nurse practice act
8 members (appointed by the Governor for 3 year Term)
5 RNs
2 LPNs
1 resident of the state of Indiana
This makes up the…
Indiana State Board of Nursing (ISBN)
***Created by elected legislated bodies
Either Criminal or Civil
Statutory Law (Nurse Practice Act)
Concerned with behavior detrimental to society as a whole (Violation of criminal law is a crime
Criminal law
Concerned with legal rights and duties of private persons. Does not threaten society as a whole. Encourages fair and equal treatment. Violation is called a Tort. A wrong committed by a person against person or another person’s property. Examples: -negligence and malpractice-invasion of privacy-assault and battery-libel and slander
Civil law
Willful acts that violate another’s rights
Assault, Battery, Defamation
Intentional
Such as negligence of malpractice
Unintentional
Conduct that falls below the standard of care
- An act that resulted in harm to another person
- The omission of an act that would have prevented harm
Negligence
What creates proof of negligence
The nurse owed a duty to the patient.
The nurse did not carry out the duty of breached it.
The patient was injured.
The patient’s injury was caused by the nurse’s failure to carry out that duty.
That part of the law of negligence applied to the Professional Person.
It is the failure of a professional person to act within acceptable standards of his/her profession.
Malpractice
What are the 4 elements to malpractice
Duty
Breach
Injury
Cause
Patient’s agreement to allow something to happen after being provided complete information
Risks, benefits, alternatives, consequences of refusal
Informed consent
Informed consent requirements
Brief, complete explanation of the procedure or tx must be given
Names and qualifications of persons performing and assisting in the procedure
Description of the serious harm that may occur
Explanation of alternative therapies to the proposed procedure, as well as, risk of doing nothing
Patient must be advised of his/her right to refuse the procedure (can refuse even after procedure has begun)
The patient must be capable of understanding the information
Anyone who performs a procedure on a patient without consent could be found committing: Battery
A signed form is a RECORD of the informed consent… not the actual informed consent itself
Nurse witnesses the written consent and the signature is verification that the patient voluntarily gave consent
It is the responsibility of the person forming the procedure to inform the patient about the procedure.. NOT THE NURSE
when a patient allows a procedure to be done (such as an injection) without signing a form
Implied consent
The nurse’s signature on a consent form confirms
The patient gave consent voluntarily
The signature is authentic
The patient appears competent to give consent
Verification that the patient was informed about a proposed treatment
3 groups unable to give consent
Minors or adults with appointed guardians
Persons who are unconscious or injured so that they are unable to give consent
Mentally ill persons who have been judged by professionals to be incompetent.
a damaging written statement that defames a person’s character
Libel
a damaging oral statement that defames a persons character
Slander
Attempt or threat to harm another, coupled with the ability to harm
Patient believes harm will come as a result of the threat
No actual contact is necessary
Example: the nurse threatens to restrain a patient if he doesn’t do as he/she asks
Assault
Any intentional touching of another’s body, or touching/holding without consent
Injury is not a requirement
If the nurse actually restrained the patient in the previous example
Always includes an assault.
Battery
Gives hospitals the right to deny admission to abortion clients
Gives health care personnel the right to refuse to participate in abortions
Protects agencies and employees from discrimination and retaliation
Conscience clauses
Generally written when the client or proxy has expressed the wish for no resuscitation in the event of a cardiac or respiratory arrest
Must be clearly documented, reviewed and updated periodically
Should be discussed fully with the client (if able), family, proxy (if appropriate) and the health care team
Institutional committees may be called upon to resolve conflicts that may arise
DNR (Do Not Resuscitate)
- Being answerable for professional conduct.
2. To assume responsibility.
Accountability
To whom is the nurse accountable?
Herself/himself The patient The employer The profession Society
What are nurses accountable for?
For all professional nursing activities.
By what criteria is accountability measured?
Standards of Nursing Care
Designed to protect medical practitioners who provide assistance at the scene of an emergency.
Limit liability and offer legal immunity for those offering help.
Must still perform within accepted standards.
Good Samaritan Act
Guidelines for the Good Samaritan Act
Limit actions to those normally considered first aid – if possible
Do NOT perform actions you do not know how to do
Offer assistance, but do not insist
Do not leave the scene – send someone else for assistance
Do not accept any compensation
shared only with the patient’s informed consent, when legally required or where failure to disclose the information could result in significant harm.
Confidential information
relates to the patient’s expectation and right to be treated with dignity and respect.
Privacy
*federal legislation that establishes a
minimum level of privacy protection
*defines individually identifiable information and establishes how this information may be used, by whom and under what circumstances.
Basically, restricts the use of individually identifiable information, except for purposes of treatment, payment or health care operations unless otherwise authorized by the patient.
This means you can use patient information during the course of caring for the patient, but you have to safeguard the information from being disclosed without authorization in other circumstances (ie: being overheard by bystanders)
HIPAA (Health Insurance Portability and Accountability Act)
Used for risk management for the facility.
Document an objective description of what occurred and follow-up care.
Not part of the chart. It is for facility use.
Incident report
a legal document
the client’s health care record
the storage place of all the documentation concerning the status of the client and the care provided.
Used by all members of the health care team
A Chart
7 purposes of charting
Legal documentation Assessment Communication Research and statistics Auditing/quality assurance Billing/reimbursement Education
What is written in the client’s record or what you observe in the client’s record is
Confidential
Anything written or printed that is relied on as a record of proof for authorized persons
A legal account of how the nurse fulfills her/his professional responsibilities
Charting
- Focuses on one diagnosis.
- It is client-centered.
- Follows the nursing process.
Major components: Data Base – usually completed by nurse Problem List-listed in chronological order, NOT in order of priority Initial Care Plan Progress Notes Discharge Summary
POMR (Problem orientated medical record)
Advantages of PIE charting
emphasizes nursing diagnosis and evaluation
A chronological written account of the client’s status, nursing interventions provided and the effectiveness of the interventions
Narrative nurses notes
Whats the organization of notes when doing charting or focused charting
DAR:
data (objective and subjective)
actions (interventions)
response (evaluation)
Standards of practice are integrated into documentation forms
Nurse only documents significant findings or exceptions to the pre-defined norms
Charting by exception (CBE format)
A separate portable form kept at the nurse’s station – easily accessible.
Contains information needed for daily client care.
Should reflect the client’s most current activities
May be kept separately from the rest of the charting
Kardex
3 types of Kardex
Patient
Medication
Treatment
Describes client outcomes that respond to nursing interventions.
Broadly stated – must be made more specific for each client.
Each outcome includes a 5-point scale to rate the client’s status.
Nursing Outcomes Classification (NOC)
Pertinent information is shared between nurses at the change of a shift.
Can be done orally or written or a combination of both.
Shift report
Standard information to share at a shift report
Client’s name, age, room number, diagnosis, physician(s).
Diet, activity status
Any scheduled tests or procedures and specific instructions (ie, NPO)
IV access and fluids
Pain level and management
Any abnormal findings in the physical/head-to-toe assessment
Any changes in client status during the shift
Any orders that need to be continued onto the next shift.
Charting guidelines
Follow agency policy
Know when, where and what to chart
Chart promptly
Use approved abbreviations for the facility
Be brief, concise, clear and to the point
Observations, not interpretations
Be accurate
Write legibility
Watch your spelling and grammar
Document as soon as possible after providing nursing care – helps avoid errors
Document contact with colleagues such as physicians, supervisors or other nurses
Thoroughly document any client refusal of treatment
Document any client teaching done
occurring from a procedure
a. urinary tract infection
Iatrogenic
originating from the facility or its personnel
b. Salmonella (food poisoning)
Exogenous
patient’s normal flora becomes altered and an overgrowth results.
Endogenous
List the chain of infection
Infectious agent or pathogen Reservoir or source for pathogen growth Portal of exit Mode of transmission Portal of entry Susceptible host
The sources of microorganisms.
Examples: humans, plants, animals, the environment, insects, birds, food, water, milk, feces.
Resevoir
Environmental requirements for organisms to survive
- food: food or soil
- oxygen: aerobic and anaerobic
- water: most require water or a moist environment
- temperature: human pathogen ideal temp is 95F
- pH: most microorganisms prefer 5-8
- light: microorganisms thrive in darkness
Cold temperatures tend to prevent growth and reproduction
Bacteriostasis
Temperature that destroy bacteria
Bactericidal
Portals of exit for the reservoir
Respiratory tract (through mouth, nose, artificial airway)
GI tract (mouth, bowel)
Urinary tract (with UTI)
Blood
Skin (cut or wound)
Reproductive Tract (semen, vaginal discharge)
Examples of direct transmission
- touching, biting, kissing, intercourse
- droplet spread if within 3 feet of each
- other (sneezing, coughing, spitting, singing, talking)
Examples of indirect transmission
1) Vehicle-borne: substance that transports and introduces the infectious agent.
Fomites (inanimate objects): toys, clothes, utensils, water, food, etc.
2) Vector-borne: animal or insect that transports infectious agent
C. Airborne Transmission - droplets or dust carry the infectious agent.
Factors increasing susceptibility to infection
Age Heredity Certain diseases Stress Nutritional state Medical therapies Medications
interval between entrance of pathogen into body and first S&S.
no signs & symptoms to beginning of general malaise
Incubation period
interval from onset of nonspecific S&S to more specific ones.
general malaise, fever, achy
Prodromal stage
interval when S&S specific to the type of infection occur.
congestion, cough, runny nose, etc.
Illness stage
interval when acute S&S disappear.
5th – 7th day usually
Convalescence
Infection can be _____ such as a wound infection, urinary tract infection, etc.
Localized
Infection can be _____ infection affects entire body (can be life threatening)
Systemic
Standard precautions
- Used in the care of all hospitalized clients, regardless of diagnosis or infection status.
- Applies to blood, body fluids, broken skin, mucous membranes.
- Wash hands after contact with above whether or not gloves were worn.
- Wear gloves when touching above or contaminated items.
- Wear mask, eye protection, or face shield if splashes or sprays can be expected.
- Wear gown to protect clothing if splashes or sprays could occur.
- Handle equipment contaminated with above carefully to prevent transfer of microorganisms
- Special handling of contaminated linen .
- Prevent injuries from used scalpels, needles & place in puncture-resistant containers.
Transmission based precautions consist of what 3 precautions
Airborne
Droplet
Contact
Staphylcoccus aureus
Common bacteria found on the skin and nasal cavity of both humans and animals
Commonly causes boils and soft-tissue infections
Colonization occurs in:
Armpit, Inside of nose (most frequent), Groin, Genital area
Transmitted by direct or indirect contact with body fluids
Correct handwashing
Wash your hands often with warm soapy water, use friction and scrub for 20 seconds
Use 60% alcohol-based hand sanitizer when soap and water are not available
Proper donning order
- Wash Hands
- Gown
- Face Mask (all types)
- Goggles
- Gloves
the standard of care which is what those acting under the same or similar circumstances would do.
Duty
You must do something or fail to have done something that others would have done acting under the same or similar circumstances
Breach
the breach of duty caused the harm to occur.
Cause
Created by administrative bodies such as the State Board of Nursing to enforce statutory law.
Administrative law
Created by judicial decisions made in court (such as informed consent). Interprets statutory laws.
Common law
