Midterm Flashcards
Assessment
Primary and secondary source
Collection of data from primary source (patient) and Secondary source (family, other health pros, med records, med lit).
Assessment
Deliberate and systematic collection of data. Interpretation of data. Documentation of data.
Diagnosis
The clinical judgement concerning the patient’s response to health conditions/life processes.
An analysis and synthesis of data put into focus notes and charting
Maslow’s hierarchy of needs
Helps prioritize the components of nursing diagnosis. Physiological needs Safety Love/belonging Esteem Self-actualization
What comes first with diagnosis?
ABCs
Planning
Collaborates with pt and healthcare team to determine urgency of identified problems.
Prioritizes patient’s needs.
Design goals.
Goals should be what?
SMART Specific Measurable Attainable Relevant Time bound
Different types of nursing interventions
Independent, collaborative, and dependent.
Independent require no order
Collaborative are in conjunction
Dependent require an order
Implementation
The execution of the care plan.
Any treatment the nurse performs to enhance pt outcomes
Evaluation
Examining results according to data collected.
Comparing achieved outcomes with goals.
Recognize errors.
A continuous review.
Correct order of nursing process
Assessment Diagnosis Planning Implementation Evaluation
Three parts of a diagnosis
The problem
The etiology
The defining characteristics
Problem:
The diagnostic label
Ex imbalanced nutrition
Etiology
What is causing or contributing to the problem? Described as related to (RT)
Ex. Less than body requirements RT chronic diarrhea, nausea, and pain
Defining characteristics
Evidence of the problem. As evidence by (AEB) or as manifested by (AMB)
Ex AEB he aight 5’5” weight 105 lbs
Three types of nursing diagnoses
Actual/problem focused
Risk
Wellness/health promotion
Appropriate documentation
Succinct Avoid generalizations Subjective data: symptoms Objective data: signs Observe, verify, infer
Verify
Confirming something
Validate
Comparison of data with another source to determine data accuracy
Observation
Patient’s nonverbal and verbal behaviors
Observation of cues
See if your observations of the patient matches what the patient is verbally describing
Inference
Your judgement or interpretation of a cue
Inductive reasoning
Cognitive process where one identifies a specific idea or action, then makes conclusions about general ideas
Seductive reasoning
Cognitive process where one examines a general idea and then considers a specific action or idea
Proper documentation of an incident
An incident report.
Provides a database for further investigation in an attempt to determine any deviation from standards of care
Safe body mechanics when lifting
Assess weight - determine if assistance needed
Use safe patient handling equipment if patient is unable to help
Use lift teams of two
Meaning if colonized organisms
Colonization occurs when a microorganisms invades a host, but does not cause infection
Safety risk factors: fetal
Maternal smoking
Alcohol consumption
Addictive drugs
X ray first trimester
Safety risk factors: infant
Falling, suffocation, choking, burns, car accident, crib injury, electric shock, poisoning
Safety risk factors: toddler
Physical trauma, falling, cuts, car accident, burn, poisoning, drown, electric shock
Safety risk factors: school age
Injury, choking, suffocation, obstructed airway or was, poisoning, drowning, fire, burns, harm from people or animals
Safety risk factors: adolescent
Car accident, Rec injuries, firearms, substance abuse
Safety risk factors: older adults
Falls, burns, car accidents, pedestrian injuries
Which nursing procedures require sterile techniques
Wound dressing
Foley catheter
Behavior restraints:
Written restraint orders following evaluation are okay but only for 4 hours. Pt must be continually monitored
Medical restraints:
Can be used up to 12 hours after dr orders. Order must be renewed daily. Must state reason and time.
Which patients are most at risk for infections?
Very young and the elderly
Older adults susceptibility to infection
Immune senescence: age related functional deterioration Decreased lymphocyte production Increased risk of HAIs Recommend flu and pneumonia vaccines Educate hand hygiene
Risk of infection: chronic disease
Cause pneumonia, skin breakdown, and venous stasis ulcers
Risk of infection: lifestyle
STIs, HIV, HBV, infections, or liver failure
Risk of infection: occupation
Black lung disease, pneumonia, TB, poor nutrition, or excess stress
Risk of infection: diagnostic procedures
Cause multiple iv lines and immunosuppressive drugs
Risk of infection: travel
Meningitis or acute respiratory distress
Risk of infection: trauma
Sepsis or secondary infection
Risk of infection: improper nutrition
Impaired immune response
Factors affecting: pulse rate
Exercise Temp Emotions Medications Hemorrhage Postural changes Pulmonary conditions
Factors affecting: respiratory rate
Exercise Acute pain Anxiety Smoking Body position Medications Neurological injury Hemoglobin function
Factors affecting: temperature
Age Exercise Hormone level Circadian rhythm Stress External environment
4 ways to transfer body heat
Radiation: one surface to another without direct contact
Convection: transfer by air movement
Evaporation: transfer of heat energy by liquid changing to a gas
Conduction: one object to another through direct contact
Factors affecting: blood pressure
Age Stress Ethnicity Gender Daily variation Medications Activity Smoking
Patient conditions that require specific nursing actions: temperature
Risk for imbalanced body temp, hyperthermia, hypothermia, ineffective thermoregulation
Patient conditions that require specific nursing actions: pulse
Risk for activity intolerance, anxiety, decreased CO, deficient fluid volume, impaired gas exchange, acute pain, ineffective peripheral tissue perfusion
Patient conditions that require specific nursing actions: blood pressure
Risk for hypotension, hypertension, orthostatic hypotension, activity intolerance, anxiety, decreased CO, deficient fluid volume, risk for injury, acute pain, ineffective tissue perfusion
Patient conditions that require specific nursing actions: respirations
Risk for activity intolerance, ineffective airway clearance, anxiety, ineffective breathing pattern, impaired gas exchange, acute pain, ineffective peripheral tissue perfusion, dysfunctional ventilators weaning response
Most accurate temp?
Most used?
Rectal - 37.5
Oral - 37
How often do you check vitals after a procedure?
On arrival After 30 min Every hour the first 3 hours Every 4 hours for 72 hours Every shift after 72 hours
