Nuft 202 Exam 2 Flashcards

Question

Patient data is

Answer 1

usually your best source of information. Patients who are conscious, alert and able to answer questions without cognitive impairment provide the most accurate information.

Answer 2

in cases of severe illness or emergency situations, families are often the only source of information for health care providers

Answer 3

is a valuable tool for checking the consistency and similarities of data with your personal observations

Answer 4

is an organized conversation focused on learning about the well and the sick as they seek care. This becomes the basis for forming trust and an effective long term therapeutic relationships with patients.

Answer 5

Courtesy Comfort Connection Confirmation

Answer 6

greeting patients by preferred names Introducing yourself and explaining your role meeting and acknowledging any visitors in a patients room and learning their names

Answer 7

In a hospital setting performing any necessary comfort measures before beginning the interview

Answer 8

establishing eye contact and sitting at eye level if possible during an interview not dominating a discussion or assuming that you know the nature of a patients problems. Start with open ended questions listen and be attentive use your observation skills respect silence and be flexible 'let the patients needs, concerns, or questions guide your follow up questions

Answer 9

Asking the patient to summarize the discussion so there are no uncertainties Being open to further clarification or discussion

Answer 10

-orientation and setting an agenda -working phase -terminating an Interview

Answer 11

Set the scene! Your aim is to set an agenda for how you will gather information about a patient current chief concerns or problems -explaining your purpose -asking patient for his or her list of concerns/problems -nothing that all information will be confidential

Answer 12

start an assessment or a nursing health history with open ended questions that allow patients to describe more clearly their concerns or problem

Answer 13

Summarize your discussion with a patient and check for accuracy of the information collected Give your patient a clue that the interview is coming to an end

Answer 14

Observation Open-ended questions Leading questions Back channeling Direct closed-ended questions

Answer 15

The gathering of information through nonverbal behavior, appearance, and interaction with the environment, you determine whether the data you obtained are consistent with what the patient states verbally This will help you lead to pursue further objective information to form accurate conclusions

Answer 16

-elicit a patient's unique story. -gives a patient the ability to decide how much information to disclose -for example, "So, tell me more about..." or "What are your concerns about this?" This approach does not lead to a specific answer.

Answer 17

These are the most risky questions because of possibly limiting the information provided to what a patient thinks you want to know Two examples of leading questions are (1) "It seems to me this is bothering you quite a bit. Is that true?" and (2) "That wasn't very hard to do, do you agree?"

Answer 18

Active listening technique that Reinforces your interest in what a patient has to say by using good eye contact and listening. includes active listening prompts such as "all right," "go on," or "uh-huh." This technique shows that you have heard what a patient says, are interested in hearing the full story, and are encouraging the patient to give more details.

Answer 19

As patients tell their stories, encourage a full description without trying to control a story's direction. This requires you to probe with more open-ended questions, such as "Is there anything else you can tell me?" or "What else is bothering you?" Each time a patient offers more detail, probe again until the patient has nothing else to say and has told the full description. Always be observant. If a patient becomes fatigued or uncomfortable, know that it is time to postpone the interview until later.

Answer 20

Questions that can be answered with short responses such as "yes" or "no." or a number of frequency of a symptom —————————————————— For example, the nurse asks, "How often does the diarrhea occur?" and "Do you have pain or cramping?" This technique requires short answers and clarifies previous information to provide a more comprehensive database. The questions do not encourage patients to volunteer more information than you request.

Answer 21

You gather a nursing health history during either your initial or early contact with a patient. It’s a Major part of assessment. Includes biographical information, reason for seeking health care, patient expectations, present illness or health concerns, health history, family history, environmental history, psychosocial history, spiritual health, review of systems, and documentation of history findings.

Answer 22

adapts each assessment to the unique needs of patients of background and cultures different from your own Be respectful understand these differences do no impose on your own attitudes, biases, and beliefs

Answer 23

biographic data chief complaint history of present illness past history family history of illness lifestyle social data psychological data patterns of health care

Answer 24

Factual demographic data; age; address; occupation; working status; marital status; source of health care; and types of insurance

Answer 25

is a brief statement about why a patient (in the patient's own words) is seeking health care

Answer 26

A Patient's understanding of why he or she is seeking health care. The assessment of patient expectations is not the same as the reason for seeking medical care, although they are often related. Failure to identify a patient's expectations of health care providers results in poor patient satisfaction.

Answer 27

Essential and relevant data about the nature and onset of symptoms. Follow Acronym PQRST: Provokes Quality Radiates Severity Time —————————————————— P-Provokes (precipitating and relieving factors): How did it come about? What might be the causes for the symptom? What makes it better or worse? Are there activities (e.g., exercise, sleep) that affect it? Quality: What does the symptom feel like? (Have patients explain in their own words.) If the patient has difficulty in describing symptoms, offer probes (e.g., "Is the pain sharp? Dull?" or "Do you feel light-headed, dizzy, off-balance?"). What does the illness or symptom mean to the patient? R-Radiate: Where is the symptom located? Is it in one place? Does it go anywhere else? Have the patient be as precise as possible. S- Severity: Ask the patient to rate the severity of a symptom on a scale of 0 to 10 (with no symptom at 0 and the worst intensity at 10). This gives you a baseline with which to compare in follow-up assessments. -Time: Assess the onset and duration of symptoms. When did the symptom first occur? Does it come and go? If so, how often and for how long? What time of day or on what day of the week does it occur? Also assess whether the patient is experiencing other symptoms along with the primary symptom. For example, does nausea accompany pain? Does the patient have pain along with shortness of breath?

Answer 28

provides a holistic view of a patient's health care experiences and current health habits Medical history surgical history medication history Allergies Social History

Answer 29

history that includes data about immediate and blood relatives. This also reveals info about the family structure, interaction, support, and function

Answer 30

provides information about a patient's support system, which often includes a spouse or partner, children, other family members, and close friends. Also includes how the patient typically copes with stress

Answer 31

The spiritual dimension represents the totality of one's being and is difficult to assess quickly. Review with patients their beliefs about life, their source for guidance in acting on beliefs, and the relationship they have with family in exercising their faith. Also assess rituals and religious practices that patients use to express their spirituality. Patients may request availability of these practices while in a health care setting.

Answer 32

A systematic approach for collecting the patient's self-reported data on all body systems.

Answer 33

- It is important to closely observe a patient's verbal and nonverbal behaviors. - Adds depth to objective database - Observations direct you to gather additional objective information to form accurate conclusions about the patient's condition. - An important aspect of observation includes a patient's level of function: the physical, developmental, psychological, and social aspects of everyday living.

Answer 34

These data are valuable in confirming observational findings (eg, ifa sample of urine is cloudy in appearance, a specimen of urine examined by a culture test can indicate if infection is present). The data can also direct nurses to explore a patient's condition more fully (e.g., if an x-ray of the chest suggests lung congestion, the nurse will auscultate lung sounds to further determine extent of congestion).

Answer 35

the successful ongoing interrelation and validation of assessment data ensure that you have collected a complete database.

Answer 36

this is clinical reasoning you are determining the presence of abnormal findings, recognizing that further observations are needed to clarify information, and beginning to identify a patients health problems

Answer 37

validate the information you have collected to avoid making incorrect inferences Validation of assessment is the comparison of data with another source to determine data accuracy Gives you the opportunity to clarify vague or unclear data

Answer 38

record the results of the nursing health history and physical examination in a clear, concise manner using appropriate terminology. this information becomes the baseline to identify patient health problems, plan and implement care, and evaluate a patient's response to interventions.

Answer 39

Visual representation that allows you to graphically show the connections among a patient's many health problems

Answer 40

is a clinical judgement concerning a human response by a patient that a nurse is competent to treat

Answer 41

actual or potential health problem that may occur from complications of disease, diagnostic studies, or the treatment regimen; the nurse works together with other members of the health care team toward its resolution

Answer 42

First introduced in 1950 In 1953, Fry proposed the formulation of a nursing diagnosis. In 1973, the first national conference was held. In 1980 and 1995, the American Nurses Association (ANA) included diagnosis as a separate activity in its publication Nursing: a Social Policy Statement. In 1982, NANDA was founded.

Answer 43

North American Nursing Diagnosis Association International

Answer 44

was established with the purpose to develop, refine, and promote a taxonomy of nursing diagnostic terminology for use by all professional nurses

Answer 45

defines nursing diagnosis as the diagnosis and treatment of human response to health and illness

Answer 46

Organization whose membership consists of the board of nursing of each state or territory.

Answer 47

problem-focused Risk Health Promotion

Answer 48

describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community.

Answer 49

Patient behavior physical signs

Answer 50

an etiological or causative factor for the diagnosis; Allows a nurse to individualize a problem-focused nursing diagnosis for a specific patient need

Answer 51

a clinical judgement concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes NO defining characteristics or related factors but there are risk factors

Answer 52

Are environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem These factors help in planing preventative health care measures

Answer 53

a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential Expressed by a readiness to enhance specific health behaviors Have only defining characteristics with some related factors used to improve understanding

Answer 54

Experience

Answer 55

this reasoning process involves using the assessment data you gathered about a patient to logically explain a clinical judgement

Answer 56

Data clustering identifying patient health problems formulating the diagnosis

Answer 57

is a set of signs or symptoms gathered during assessment that you group together in a logical way. are patterns of data that contain defining characteristics—clinical criteria that are observable and verifiable. Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion. Ex. Tonya is clustering together cues that begin to form a pattem, leading her to monitor the patient more closely for developing signs of infection.

Answer 58

an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion

Answer 59

interpreting data more accurately, review all characteristics or risk factors, eliminate irrelevant ones, and confirm the relevant ones. Compare results to the NANDA diagnoses

Answer 60

-identifying the correct diagnostic label with associated defining characteristics or risk factors and a related factor - a related factor allows you to individualize a nursing diagnosis for a specific patient

Answer 61

Pathophysiological Treatment related Situational Maturational

Answer 62

P - problem E - etiology S - symptoms SEP

Answer 63

Consider patients' cultural diversity when selecting a nursing diagnosis. Ask questions such as: Which practices within your culture are important to you? Cultural awareness and sensitivity improve your accuracy in making nursing diagnoses. -have Empathy towards your patients

Answer 64

a way to graphically represent the connections between concepts and ideas that are related to a central subject such as a client's health problem. Concept maps promote problem solving and critical thinking skills by organizing complex client data, analyzing concept relationships and identifying interventions. Advantages of this concept is its central focus on a patients rather than on the disease or health alteration

Answer 65

Lack of knowledge or skill *Inaccurate data * Missing data * Disorganization Errors can occur in all steps of the nursing diagnostic process

Answer 66

the nurse collaborates with a patient and family and the rest of the health care team to determine the urgency of the identified problems and prioritize patient needs

Answer 67

nursing diagnoses that, if untreated, result in harm to a patient or others -ex. those related to airway status -circulations -safety and pain

Answer 68

high intermediate low

Answer 69

involve non-emergent, nonlinear- threatening needs of a patient

Answer 70

not always directly related to a specific illness or prognosis but affect a patient's future well-being. -ex. patients long term health care needs

Answer 71

Assess patient identify problems prioritize problems identify desired outcomes identify interventions for achieving outcomes prioritize interventions deliver patient care evaluate interventions

Answer 72

a broad statement that describes a desired change in a patient's condition or behavior -think of this as an ultimate outcome and expected outcomes as the measurable changes that must be achieved to reach a goal

Answer 73

measurable change that must be achieved to reach a goal -behavior -physical state -perception

Answer 74

patient will ambulate independently in 3 days

Answer 75

Subject + verb + condition + performance criteria/qualifier + target time (Ex. "The patient will drink 1000 mI. in 24 hours.") - patient ambulates in the hall 3 times a day by 4/22

Answer 76

must be patient-centered SMART acronym (specific, measurable, attainable, realistic, timed)

Answer 77

independent nursing actions that involve carrying out nurse-prescribed interventions written on the nursing plan of care, as well as any other actions that nurses initiate without the direction or supervision of another health care professional and that result from their assessment of patient needs

Answer 78

positioning a patient to prevent pressure ulcer formation, instructing patients in side effects of medications, providing skin care to an ostomy site

Answer 79

interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care providers. Check for errors or incorrect therapies

Answer 80

a valuable resource for selecting appropriate interventions and activities for your patient. Developed by IOWA intervention project. Correctly written nursing interventions include actions, frequency, quantity, method, and the person to perform them.

Answer 81

Domains Classes Interventions

Answer 82

includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings so any nurse is able to quickly identify a patient's clinical needs and situation.

Answer 83

Visual representation of all of a patient's nursing diagnoses that allows you to diagram interventions for each 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

Answer 84

to deliver timely care at each phase of the care process for a specific type of patient -they improve continuity of care because they clearly define the responsibility of each health care discipline.

Answer 85

treatments performed through interactions with patients

Answer 86

patient received direct intervention in the form of medication administration, urinary catheter insertion, discharge instruction or counseling

Answer 87

a treatment performed away from the patient but on behalf of a patient or group of patients

Answer 88

managing a patients environment, documentation and interdisciplinary collaboration

Answer 89

These orders reflect health care provider treatment preferences and are common in critical care settings and other specialized acute care settings where patients' needs change rapidly and require immediate attention. An example of such a standing order is one specifying certain medications such as diltiazem and amiodarone for an irregular heart rhythm. After assessing a patient and identifying the irregular rhythm, a critical care nurse gives the specified medication without first notifying the health care provider because the standing order covers the nurse's action. After completing a standing order, the nurse notifies the health care provider.

Answer 90

developed by University of Iowa offers standardized language that nurses can use to describe sets of actions in delivering nursing care. this enhances communication of nursing care across settings and providing the ability to compare outcomes

Answer 91

include competencies for establishing professional and caring relationships, using evidence based interventions and technologies, providing ethical holistic car across the life span to diverse groups

Answer 92

Quality and Safety Education for Nurses These standards are authoritative statements of duties that all RNs are expected to perform competently, regardless of role, patient population they serve, or specialty

Answer 93

Patient: make sure that they are physically and psychologically comfortable. -offer comfort measures before initiating interventions to help patients participate more fully -do not rush care Environment: patient safety is your first concern. A patients care environment needs to be safe and conductive to implementing therapies. -patients benefit most from nursing interventions when surroundings are compatible with care activities. Time management: inadequate nursing time contributes to poor quality of patient care, and excess nursing time contributes to high cost of care Equipment: decide which supplies you need and determine they availability Personnel: as a nurse you are responsible for deciding whether to perform an intervention, delegate it to an unlicensed member of the nursing team, or have an RN colleague assist you. -Delegation

Answer 94

Cognitive skills: critical thinking and decision making skills -Always use good judgement and sound clinical decision making when performing any intervention. Interpersonal skills: Good interpersonal communication keeps patients informed and engaged in decision making, provides individualized instruction, and supports patients who have challenging emotional needs. Helps develop a trusting relationship, express a level of caring, and communicate clearly with patients and their families Psychomotor skills: these skills are required for the integration of cognitive and motor activities. With time and practice you learn to perform skills correctly, smoothly, and confidently.

Answer 95

Include skills such as shopping, preparing meals, housecleaning, writing checks, and taking medications. -Nurses within home care and community health settings frequently heck patients adapt ways to perform IADLs. -Occupational Therapists are specifically trained to adapt approaches for patients to use when performing IADLs

Answer 96

assessment skills and techniques (observations, physiological measurements, patient interview)

Answer 97

Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of patient, family and community outcomes developed to evaluate the impact of interventions provided by nurses or other health care professionals

Answer 98

It involves a nurses ability to recognize how a patient is responding and then adjust interventions as a results. A nurse will change the frequency of an intervention, change how the intervention is delivered, or select a new intervention.

Answer 99

goal been met? expected outcomes met? Does the patient agree? you and your patient both agree Document the discontinued plan.

Answer 100

a procedure for detecting changes in a patient's condition. It involves four steps: repeating the primary assessment, repeating and recording vital signs, repeating the physical exam, and checking interventions.

Answer 101

examines two factors: the appropriateness of the intervention selected and the correct application of the intervention -Appropriateness is based on the standard of care for a patients health problem

Answer 102

the minimum level of care accepted to ensure high quality of care to patients

Answer 103

resolve actual health problems prevent potential problems maintain a healthy state

Answer 104

Severe pressure injuries, falls in trauma, catheter – associated urinary tract infections, CAUTIs (make sure tubing is set up to flow properly to prevent back up of urine which can cause infection) central line-associated bloodstream infections CLABSIs (goes directly into the heart)(preventing by cleaning, or changing IV line)

Answer 105

Involving family as much as possible collaborating with healthcare team also, you can call provider and notify that patient is at risk for infection

Answer 106

Not meeting goals having to reassess to meet ultimate goal, revision of plan

Answer 107

Standards and attitudes for evaluation Experience environment knowledge Evaluate and SEEK

Answer 108

Well designed, systematically conducted research studies found in scientific, peer review journals

Answer 109

Problem – solving approach to clinical practice that combines the best evidence with a clinicians expertise, patient preferences and values, and healthcare resources in making decisions about patient care

Answer 110

CASCIEC Come and sleep cause I enjoy class 1. Cultivate a spirit of inquiry. (curiosity) 2. Ask a clinical question in PICOT format. 3. Search for the best evidence. 4. Critically appraise the evidence. 5. Integrate the evidence. 6. Evaluate the outcomes of practice decision or changes. 7. Communicate the outcomes of the evidence-based practice decision.

Answer 111

P= Patient population of interest | = Intervention of interest C = Comparison of interest 0 = Outcome T= Time Doesn’t have to be in order Example: "Does the use of chlorhexidine (I) compared with alcohol (C) for cleaning CVC insertion sites in hospitalized patients (P) affect the incidence of CLABSI (O) within 6 months (T)?

Answer 112

Level one: Systematic review of meta-analysis of randomized controlled trials (RCTs) evidence – based clinical practice guidelines based on systematic reviews.

Answer 113

Experimental Design

Answer 114

Quantitative is better because you get numbers and data

Answer 115

Level I Systematic review or meta-analysis of randomized controlled trais (RCTS) Evidence-based clinical practice guidelines based on systematic reviews Level II A well-designed RCT Level Ill Controlled trial without randomization (quasiexporimental study) Level IV Single nonexperimental study (case-control, correlational, cohort studies) Level V Systematic reviews of descriptive and qualitative studies Level VI Single descriptive or qualitative study Level VII Opinion of authorities and/or reports of expert committees

Answer 116

Introduction: It will either draw you in it not

Answer 117

Experimental research is the best. Ex. RCTs get numbers data from this objective design ———————————— Non-experimental research (No randomization) ex: case control study ————————- Surveys ———————— Correlation Study: relationship between 2 variables Ex. The more someone exercises, the more weight they lose (POS correlation) Ex. The more money you spend the less money you have. (Neg correlation)

Answer 118

Inductive reasoning Get understanding of a situation Generalized study Find commonalities

Answer 119

Medications Vaccinations Implementing a new drug

Answer 120

Preclinical and animal studies Phase 1: clinical trials (study done on small group of humans) Phase 2 and 3: tested on larger group of humans Phase 4: clinical trials-translate to practice Phase 5: translate to community

Answer 121

A formal approach for the analysis of health care-related processes

Answer 122

Excellent patient care and outcomes

Answer 123

Specific Measurable Attainable Relevant Timely

Answer 124

Methods for Prioritizing Lowest level has highest priority Self actualization A desire to become the most that one can be Esteem Respect, self-esteem, status, recognition, strength, freedom Love and belonging Friendship, intimacy, family, sense of connection Safety needs Personal security, employment, resources, health, property Physiological needs Air, water, food, shelter, sleep, clothing, reproduction

Answer 125

Involves the collection of as much information as possible about a patient, family, or community

Answer 126

Subjective: patient’s verbal description of their health problems gathered during interviews Objective: are the findings resulting from observation of patient behavior and clinical signs, as well as direct measurement, including what you see, here, and touch

Answer 127

Mercy assessment involves two steps: 1) the collection of information from as many sources as possible 2) the interpretation and validation of data to determine whether more data are needed or if the database is complete to make clinical judgments about patients

Answer 128

-Observation • Open-ended questions -Leading questions -Back channeling • Probing • Direct closed-ended questions

Answer 129

Comprehensive – full assessment Problem oriented – one problem, only ask about that problem Focus assessment – focused on a particular issue

Answer 130

Data collection: getting information about the situation Data analysis: understanding data, and comparing ring findings

Answer 131

A nursing diagnosis is a clinical judgment based on critical analysis and interpretation of data cues that classifies the response to illness by an individual, family, or Community. Medical diagnosis: the language, healthcare providers, used to communicate to patient health problems and associated treatments Collaborative problem this is the one that requires both medical and nursing interventions to treat (multiple providers)

Answer 132

a diagnostic label or diagnosis, related factor, or a etiology and defining character