mod 1.1 1.2 1.3 2.1 6.1 Flashcards

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0
Q

What are some activities done during assessment ?

A
Obtain a nursing health history
Conduct a physical assessment
Review client records
Review nursing literature 
Consult supper persons
Consult health care professionals
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1
Q

Purpose of assessment is

A

To establish a database about the clients response to health concerns or illness and the ability to manage health care needs.

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2
Q

Purpose of nursing diagnosis is

A

To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions.

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3
Q

Activities of diagnosing

A

Interpret and analyze data
-compare data against standards
-cluster or group data
-identify gaps and inconsistencies
Determine strengths, rushed and problems
Formulate nursing diagnosis and collaborative problem statements

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4
Q

What’s an actual diagnosis

A

A client problem that is present at the time of the nursing assessment.
Ex) inefffective airway clearance and anxiety.

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5
Q

What’s a risk diagnosis ?

A

A clinical judgement that a problem does not exis, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
Ex) risk for injection risk for falls.

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6
Q

What must a goal statement include?

A

A time frame, be realistic, mutually developed, observable or measurable.

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7
Q

Wholly compensatory

A

Nurse agency totally compensates for client self-care deficits.

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8
Q

Partially compensatory

A

Nurse agency supplements clients limited self-care ability.

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9
Q

Supportive educative

A

Nurse agency provides support counseling and teaching.

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10
Q

Cognitive domain of learning

A

Intellectual behavior understanding. Ex) alert and orientated and able to listen and interact

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11
Q

Affective domain of learning

A

Feelings related to values, attitudes, and opinions. Ex) asking them to change what they may value more.

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12
Q

Psychomotor domain of learning

A

Integration of mental and motors abilities. Ex) ability to use motor skills for activity, giving injection.

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13
Q

Teaching nandas

A

Deficient knowledge ex-(low-cal diet)
Readiness for enhanced knowledge ex-(exercise and activity)
Noncompliance ex-(with medication plan)

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14
Q

Teaching nanda with deficient knowledge as etiology

A

Risk for impaired parenting related to deficient knowledge(skills in infant care and feeding)
Risk for injection related to deficient knowledge (stds and their prevention)
Anxiety related to deficient knowledge (bone marrow aspiration)
Others that can be used: risk for injury, ineffective breast feeding, coping, or health maintenance

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15
Q

Teaching strategy: lecture

A

Short, but never short enough to really learn.

16
Q

Lecture-discussion

A

Allows for questions, better way to learn.

17
Q

Discussion

A

Exchange points of view, correct information, requires more time.

18
Q

Demonstration/return demonstration

A

Perform motor skill for client then have them perform it back to you. Needs practice.

19
Q

Analogs

A

Verbal instruction with familiar images.

20
Q

Group teaching

A

Support groups

21
Q

Audiovisual material

A

Use of visual and auditory stimulation, films.

22
Q

Internet

A

Information may be incomplete, misleading, or inaccurate.

23
Q

Printed material

A

Must fit reading level, use information in language used by client. 12th grade reading level is national average.

24
Q

Government responses to disaster

A

FEMA-federal emergency management agency
SEMA-state emergency management agency
CERT-community emergency response team
NDRM-National disaster medical systems(homeland security)
Red cross-volunteers

25
Q

Natural disasters

A

Tornadoes, hurricanes, earthquake, flood, storm, epidemic

26
Q

Non-disaster stage

A

Preplan when vulnerable to disaster. Threat of disasters and there is time to prepare.

27
Q

Impact stage

A

Disaster has happened, assess damage, death , loss of propert, injury

28
Q

Emergency stage

A

Help arrives, recovery begins

29
Q

Reconstruction stage

A

Restore, rebuild mitigation (minimizes the effects or prevents future disasters and makes them right)

30
Q

Nursing preparation to disaster

A
Know facilities plan
Know your role
Be supportive to patients
Carry out plan as best you can
Be available if off duty
31
Q

Opioid analgesics

A

Mainstay in the management of all types of pain. Block the release of neurotransmitters in the spinal cord.
Ex) morphine, fentanyl, hydrocodone, meperidine, methadone, codeine

32
Q

PRN medications

A

Pain medication that is given on an as needed basis after doing a pain assessment on the patient. Can only be given every few hours depending on the drug.

33
Q

PCA

A

Patient controlled analgesia. Can improve pain relief and increase patient satisfaction. Reduces anxiety which helps relieve pain.

34
Q

Analgesics in elderly

A
Metabolize drugs slower
Start low and go slow
NSAIDS – High incidence of GI bleed
Nephrotoxicity
Avoid using Demerol/Codeine (causes constipation)
Increased cognitive impairment
Slow GFR (glomerular filtration rate)
Decreased GI motility and absorption
35
Q

SE titration

A
  • You want to give the minimal dose that will give the maximum affect w/minimal side effects. (Start low & go
    slow)
36
Q

What to watch for with opioid use

A

Watch patient for Respiratory Depression, hold med if respiratory rate is less than 10.

Constipation is a main side effect of Opioids along with urinary retention and puritis (itching).

37
Q

Antagonist/antidote for opioids

A

Narcan (Nalaxone)