fundamentals SG #1 Flashcards
a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant
Critical Thinking
knowledge based on research or clinical expertise, makes you an informed critical thinker
Evidence-Based Knowledge
3 levels of critical thinking
- basic
- complex
- commitment
analytical process for determining a patients health problems
Diagnostic Reasoning
process of drawing conclusions from related pieces of evidence and previous experience with the evidence
Inference
you feel certain about accomplishing a task or goal such as performing a procedure or making a diagnostic decision
Confidence
you learn to consider a wide range of ideas and concepts before forming an opinion or making a judgment
Thinking Independently
deals with situations justly, bias or prejudice does not enter into a decision
Fairness
- responsible for correctly performing nursing care activities based on standards of practice.
Responsibility & Accountability
willing to take risks in trying different ways to solve problems. Often leads to advances in patient care
Risk Taking
misses few details and follows orderly or systematic approach when collecting information, making decisions, or taking action
Discipline
determined to find effective solutions to patient care problems
Perseverance
original thinking, finding solutions outside of the standard of care while still keeping standards of practice
Creativity
question and test their own knowledge and beliefs
Integrity
admit your limitations in your knowledge and skill
Humilty
3 ways of developing critical thinking skills
- reflective journaling
- meeting with colleagues
- concept mapping
2 steps of critical thinking approach to assessment
- Collection of information from a primary source (patient) and secondary sources (family members, health professionals, medical record)
- The interpretation and validation of data to ensure a complete database
an approach for obtaining from patients the data are needed to foster a caring nurse-patient relationship, adherence to interventions, and treatment effectiveness
Patient-Centered Interview
describes human responses to health conditions or life processes that exist in an individual, family, or community
Actual Nursing Diagnosis
describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community
Risk Nursing Diagnosis
Describes the essence of a patient’s response to health conditions in as few words as possible
Diagnostic Label
identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis
Related Factors
PES format
PROBLEM: nanda-1 label: impaired physical mobility
ETIOLOGY: related factor: incisional pain
SYMPTOMS: defining characteristics:evidence by restricted turning and positioning
reflects a patients highest possible level of wellness and independence in function
Patient-Centered Goal
is an objective behavior or response that you expect a patient to achieve in a short time, usually less than a week
Short-term Goal
preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures from specific patients with identified clinical problems
Standing Order
helps to differentiate nursing practice from that of other health care professionals
NIC Interventions
5 processes of the Implementation Process
- Reassessing the Patient
- Reviewing and Revising the Existing Nursing Care Plan
- Organizing Resources and Care Delivery
- Anticipating and Preventing Complications
- Implementation Skills
presence and growth of microorganism within a host but without tissue invasion or damage
Colonization
some of these have little to no risk for transmission
Infectious Diseases
disease can be transmitted directly from one person to another
Communicable Disease
pathogens multiply and cause clinical signs and symptoms
Symptomatic
Infectious agents (4)
- bacteria
- Viruses
- Fungi
- Protozoa
A place where microorganisms survive, multiply, await transfer to a susceptible host
Reservoir
ability to produce disease, to enter and survive in the host and the susceptibility of the host
Virulence
requires oxygen, Staphylococcus aureus
Aerobic
does not require oxygen, Clostridium difficile
Anaerobic
Most pathogens live between what temps ex: Legionella pneumophilia
20-40C (106-109F)
temperature or chemical that destroys bacteria
Bactericidal
Is skin considered a port of exit?
yes
Broad-spectrum antibiotics can lead to what? bc they have eliminated the normal flora as well.
suprainfections
containing RBCs (looks reddish/pink)
Sanguineous
containing WBCs & RBCs (white/reddish)
Purulent
are not as strong as tissue collagen and assumes the form of scar tissue
Granulation
a type of HCAI from a diagnostic or therapeutic procedure such as bronchoscopy
Iatrogenic infections
Part of the patient’s flora becomes altered and an overgrowth results
Endogenous infection
eliminating the infectious organisms and supporting the patients defenses
Acute Care
Process that eliminates many or all microorganisms with the exception of bacterial spore from inanimate objects
Disinfection
Complete elimination of destruction of all microorganisms including spores
Sterilization
energy needed to maintain life-sustaining activities for a specific period of time
Basal Metabolic Rate
polysaccharide that is the structural part of plants that is not broken down by the human digestive enzyme
Fiber
mainly from plant foods
Carbohydrates
o Essential for synthesis of body tissue in growth, maintenance and repair
o Collagen, hormones, enzymes, immune cells, DNA, & RNA
Proteins
Fat-Soluble Vitamins?
Water-Soluble Vitamins?
- A, D, E, K
2. C, B
inorganic elements essential to the body as catalysts in biochemical reactions
Minerals
- measurement system of the size and makeup of the body
Anthropometry
when the normal red tones of the light skinned patient are absent
Blanching
Nonblanchable Redness of Intact Skin o Discoloration of the skin, warmth, edema, hardness, or pain may also be present
Stage 1 Pressure Ulcer
Partial-thickness Skin Loss or Blister
o Present as a shallow open ulcer with a red-pink wound bed without slough.
o Or presents as an intact or open/rupture serum-filled or serosanginous filled blister
Stage 2 Pressure Ulcer
Full-thickness Skin Loss (Fat Visible)
o Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed
o Some slough may be present
o It may include some undermining and tunneling
Stage 3 Pressure Ulcer
Full-thickness Tissue Loss (Muscle/Bone Visible)
o Full-thickness tissue loss with exposed bone, tendon, or muscle
o Slough or eschar (black and brown necrotic tissue) may be present
o Often includes undermining and tunneling
Stage 4 Pressure Ulcer
Full-thickness tissue loss in which the actual depth of ulcer is completely obscured by slough
Unstageable/ Unclassified: Full-thickness skin of Tissue Lose- Depth unknown (Pressue Ulcer)
a purple or maroon localized area of discolored intact skin or blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear
Suspected Deep- Tissue Injury- Depth uknown
damage to the spinal cord above the sacral region, loss of voluntary control of urination
Reflex Incontinence
bladder is overly full and bladder pressure exceeds sphincter pressure, resulting in involuntary leakage of urine
Overflow Incontinency
increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions
Uremic Syndrome
awakening to void one or more times at night
Nocturia
Excessive Output
Polyuria
- urine output is decreased despite normal intake amounts
Oliguria
coffee, tea, cocoa, cola drings that contain caffeine
Diuresis
leads to the spread of organisms into the kidneys and possibly to bacteremia or urosepsis
Bacteriuria
- involuntary leakage of urine that is sufficient to be a problem
Urinary Incontinence
temporarily or permanently bypasses the bladder and urethra as the exit routes for urine
Urinary Diversion
3 common urine tests
- Urinalysis
- Specific gravity
- urine culture
when the bowel temporary stops peristalsis
Paralytic ileus
results from unrelieved constipation, collection of harden feces wedged in the rectum that a person cannot expel
Impaction
inability to control passage of feces and gas from the anus
Incontinence
temporary or permanent surgical opening in the abdominal wall. The intestine is brought through the abdominal wall to create the stoma
Ostomies
