NUR 240 Exam 2 Flashcards
1
Q
What is a litigation
A
Process of bringing and trying a lawsuit (suing someone)
2
Q
What is the plaintiff
A
The person suing
3
Q
What is the defendant
A
The person being accused of a crime
4
Q
What is public law
A
Government is directly involved (wearing a seatbelt)
5
Q
What is private law
A
Civil law; regulates relationships between people (breaking a contract)
6
Q
What is criminal law
A
Concerns state and federal criminal statutes; defines criminal actions (Murder, theft, etc)
7
Q
What is constitutional law
A
Serve as guides to legislative bodies; right to bear arms, civil rights -federal- state (workers comp, car accidents)
8
Q
What is statutory law
A
Enacted by a legislative body; nurse practice acts (each state)
9
Q
What is administrative law
A
Empowered by executive officers; (president-fed level/governor/mayor-state/local levels…state board of nursing- law enforcement)
10
Q
What is common law
A
Judiciary system reconciles controversies (court-made law- malpractice laws- prevent one set of rules for one person and another set of rules for another person)
11
Q
In what ways is nursing regulated by law
A
Nurse practice acts
Credentialing - accreditation, licensure, certification
12
Q
What are some reasons why a nurse’s license may be suspended or revoked
A
- drug or alcohol abuse
- fraud
- deceptive practice
- ## criminal acts
13
Q
What are some reasons why a nurse’s license may be suspended or revoked
A
- drug or alcohol abuse
- fraud
- deceptive practice
- criminal acts
- previous disciplinary actions
- negligence
- physical or mental impairments including age
14
Q
What is considered a crime
A
Wrong against a person or the person’s property as well as the public
- Misdemeanor - punishable by fines or less than 1 year imprisonment
- felony - punishable by imprisonment for more than 1 year
15
Q
What is considered a tort
A
A wrong committed by a person against another person or that person’s property; tried in civil court
- intentional
- unintentional
16
Q
What are some examples of intentional torts
A
- Assault and battery
- Defamation of character
- Invasion of privacy
- False imprisonment
- Fraud
17
Q
What are some examples of unintentional torts
A
- negligence
- malpractice
18
Q
what rights are given to the patients under HIPPA
A
- To see and copy their health record
- To update their health record
- To request correction of any mistakes
- To get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations
- To request a restriction on certain uses or disclosures
- To choose how to receive health information
19
Q
What are the categories of malpractice claims
A
- Failure to follow standards of care
- Failure to use equipment in responsible manner
- Failure to assess and monitor
- Failure to communicate
- Failure to document
- Failure to act as a patient advocate
20
Q
What are the four elements of liability
A
- duty
- breach of duty
- causation
- damages
21
Q
What is included under OSHA regulations
A
- use of electrical equipment
- use of isolation techniques
- use of radiation
- use of chemicals
(ensures a safe working environment)
22
Q
Is the incident report considered part of the medical record
A
No
23
Q
What are the functions of the skin
A
- protection
- body temperature regulation
- psychosocial (self esteem)
- sensation
- vitamin D production
- immunologic
- absorption
- elimination
24
Q
What are the causes of skin alterations
A
- Very thin or very obese
- Fluid loss
- Excessive moisture
- Jaundice
- Diseases (psoriasis, eczema, etc)
25
What types of wounds exist
- intentional or unintentional
- open or closed
- acute or chronic
- partial thickness, full thickness, or complex
26
What is a wound
Break/disruption in the normal integrity of the skin
27
What are the principles of wound healing
- intact skin
- hand hygiene
- systematic body response to trauma
- adequate blood supply
- no foreign material in the wound
- extent of the damage
- nutrition
28
What are the phases of wound healing
- hemostasis
- inflammatory
- proliferation
- maturation
29
What is hemostasis
- occurs immediately after injury
- blood vessels constrict; blood begins to clot
- exudate (blood and plasma) is formed causing swelling and pain
- increased perfusion leads to redness and warmth
- platelets initiate other cells to progress the healing process
30
What is the inflammatory phase
- after hemostasis (lasts2-3 days)
- WBC (leukocytes and macrophages) migrate to the wound
- leukocytes first, macrophages about 24 hours after and remain for a while (ingest debris then release growth factors to attract fibroblasts to fill in the wound
- generalized body response: general malaise
31
What is the proliferation phase
- lasts several weeks
- fibroblasts build new tissue to fill wound space
- capillaries grow across the wound
- highly vascular, granular tissue forms the foundation of scar tissue development
- A thin layer of epithelial cells form across the wound
32
What is the maturation phase
- Final stage of healing; begins about 3 weeks after the injury, possibly continuing for months or years
- Collagen is remodeled
- New collagen tissue is deposited
- Scar becomes a flat, thin, white line
33
What are some local factors affecting wound healing
- pressure
- deccication (dehydration)
- maceration (overhydration)
- trauma
- edema
- infection
- excessive bleeding
- necrosis
- presence of biofilm (layer of microorganisms)
34
What are some systemic factors affecting wound healing
- Age (children and healthy adults heal faster)
- circulation
- nutrition
- etiology (cause of the wound)
- health status
- immunosuppression
- medication use
- adherence to treatment plan
35
What are some wound complications
- infection
- hemorrhage
- dehiscence or evisceration
- fistula formation
- abcess formation
36
What is a hemorrhage
- hemostasis not reached
- bleeding
- always check post OP wounds and mark drainage on the dressing
- if saturating the dressing and not getting better, notify the doctor and surgeon immediately
37
What is a fistula
a tract from one epithelial cell to another usually due to an abcess
- name by origin and end organ (rectovaginal, endocutaneous)
38
What is an abcess
A collection of infectious material
- usually leads to the formation of a fistula to get rid of the material
39
What is dehiscence
Separation of wound layers
40
What is evisceration
complete wound separation with internal organs protruding
- usually in the abdomen
- Caused by infection, increased internal pressure, coughing and sneezing (special pillows to hug when you cough or sneeze)
41
Psychological effects on wound healing
- pain
- anxiety
- fear
- impact on ADLs
- Change on body image
42
Factors affecting pressure injury development
- mobility
- aging skin
- chronic illnesses
- malnutrition
- incontinence
- mental status
- spinal cord and brain injuries
- neuromuscular disorders
- external pressure
- friction or shearing
43
Stages of pressure injuries
stage 1
stage 2
stage 3
stage 4
unstageable
deep tissue pressure injury
44
What are the characteristics of a stage 1 pressure injury
intact skin; non-blanchable erythema (redness)
45
What are the characteristics of a stage 2 pressure injury
partial thickness skin loss with exposed dermis; red, moist base
46
What are the characteristics of a stage 3 pressure injury
full-thickness skin loss, no bone exposed
47
What are the characteristics of a stage 4 pressure injury
full-thickness skin loss; bone exposed
48
What are the characteristics of an unstageable pressure injury
full-thickness skin loss; obscured (cannot see the base of the wound)
49
What are the characteristics of a deep tissue pressure injury
persistent nonblanchable deep red, maroon, or purple discoloration
50
What are you looking at when measuring a pressure injury
- size (length and width)
- depth (from the deepest point)
- presence of tunneling or fistulas (describe based on a clock)
- percentage of red, white/yellow, and black tissue
51
How do you clean a pressure injury wound
- clean with each dressing change
- use 0.9% normal saline solution to irrigate/clean
- dry using gauze
- report drainage or necrotic tissue
52
What terms are used to assess wound drainage
- serous (clear, watery)
- sanguinous (bloody; dark is old blood bright is new blood)
- serosanguinous (mixture of both)
- purulent (yellow, green; infection, WBC, dead tissue debris)
- scant, moderate, copious (amount)
53
What characteristics of a wound would be indicate an infection
- swollen
- deep red color
- hot when palpated
- increased drainage
- purulent drainage
- foul odor
- dehisscense
54
What are some types of wound dressings
- nonadherent
- gauze dressings
- transparent dressings
55
What are the different types of drainage systems
- open system (penrose)
- closed system (Jackson-Pratt, hemovac)
56
What is a Penrose drain
- open drain system
- comes from the surgical incision to the outside of the body to drain fluid in order to avoid edema
- needs surgery to remove
57
What is a Jackson-Pratt drain
- closed drain system
- uses negative pressure to remove drainage
58
What is the Braden scale
- determines the risk of developing a pressure injury
59
What is CHA
Complimentary health approaches
- service animals
- guided imagery
- massage therapy
- supplements
60
What is allopathic medicine
Traditional medical care
61
What is holism
Connection and interactions between parts of the whole
62
What is Ayurveda
To integrate and balance the body, mind, and spirit
- treatments that include herbs, metals, minerals, and other materials; diet and exercise; and lifestyle recommendations
63
What is the process of micturation
- urinating
- detruser muscle contracts,
- internal sphincter relaxes
- urine enters the posterior urethra
- perineum and external sphincter relax
- muscle of abdominal wall contracts slightly
- diaphragm lowers
64
What are some factors affecting micturesis
- developmental factors
- food and fluid intake
- psychological factors
- activity and muscle tone
- pathologic conditions
- medications
65
Diseases associated with renal problems
- Congenital urinary tract abnormalities
- Polycystic kidney disease
- Urinary tract infection
- Urinary calculi
- Hypertension
- Diabetes mellitus
- Gout
- Connective tissue disorders
66
what medications can affect urination
- Diuretics: prevent reabsorption of water and certain electrolytes in tubules
- Cholinergics: stimulate contraction of detrusor muscle, producing urination
- analgesics and traquilizers: suppress CNS, diminish effectiveness of neural reflex
67
What medications affect urine color
- Anticoagulants: red urine/hematuria- blood in urine
- Diuretics: pale yellow urine
- Pyridium: orange to orange-red urine
- The antidepressant amitriptyline or B-complex vitamins: green or blue-green urine
- Levodopa: brown or black urine
68
What are some different urine specimens
- Routine urinalysis
- Clean-catch or midstream specimens
- Sterile specimens from indwelling catheter
- Urine specimen from a urinary diversion
- 24-hour urine specimens
- Point-of-care urine testing
69
Which patients are at risk of a UTI
- Sexually active women
- Women who use diaphragms for contraception
- Postmenopausal women
- Individuals with indwelling urinary catheter
- Individuals with diabetes mellitus
- Older adults
70
What are some reasons to catheterize a patient
- Relieving urinary retention
- Prolonged patient immobilization
- Obtaining a sterile urine specimen when patient is unable to void voluntarily
- Accurate measurement of urinary output in critically ill patients
- Assisting in healing open sacral or perineal wounds in incontinent patients
- Emptying the bladder before, during, or after select surgical procedures and before certain diagnostic examinations.
- Providing improved comfort for end-of-life care
71
What are the different types of urinary incontinence
- transient
- overflow/chronic retention
- functional
- reflex
- stress
- mixed
- total
72
What is transient incontinence
appears suddenly and lasts 6 months or less
73
What is overflow/chronic incontinence
overdistention and overflow of bladder
74
What is functional incontinence
caused by factors outside the urinary tract
75
What is reflex incontinence
emptying of the bladder without sensation of need to void
76
What is stress incontinence
involuntary loss of urine related to an increase in intra-abdominal pressure
77
What is mixed incontinence
urine loss with features of two or more types of incontinence
78
What is total incontinence
continuous, unpredictable loss of urine
79
What is a suprapubic catheter
- surgically implanted catheter through the abdominal wall
- done because of spinal cord injury or prostate cancer
- less chance of fecal contamination
- doesn't interfere with sexual activity
80
What is an ileal conduit
- Part of the small bowel connected to the ureters so that urine can leave the body in the case that the bladder has been removed
- urostomy
- mucus is a normal finding
81
What are some variables that affect bowel elimination
- Developmental considerations
- Daily patterns
- Food and fluid
- Activity and muscle tone
- Lifestyle
- Psychological variables
- Pathologic conditions
- Medications
- Diagnostic studies
- Surgery and anesthesia
82
Which foods are constipating foods
- cheese
- lean meat
- eggs
- pasta
83
What are some foods with peristaltic effects
- fruits
- vegetables
- bran
- chocolate
- alcohol
- coffee
84
What are some gas producing foods
- onions
- cabbage
- beans
- cauliflower
85
Which medications effect stool
- Aspirin, anticoagulants: pink to red to black stool
- Iron salts: black stool
- Bismuth subsalicylate used to treat diarrhea can also cause black stools.
- Antacids: white discoloration or speckling in stool
- Antibiotics: green-gray color
86
What are some types of endoscopy
- Esophagogastroduodenoscopy
- Colonoscopy
- Sigmoidoscopy
- Wireless capsule endoscopy
87
What are some indirect visualization techniques
- Upper gastrointestinal (UGI)
- Small bowel series
- Barium enema
- Abdominal ultrasound
- Magnetic resonance imaging (MRI)
- Abdominal CT scan
88
Which patients are at risk for constipation
- Patients on bedrest taking constipating medicines
- Patients with reduced fluids or bulk in their diet
- Patients who are depressed
- Patients with central nervous system disease or local lesions that cause pain while defecating
89
How do you prevent food poisoning
- Never buy food with damaged packaging.
- Take items requiring refrigeration home immediately.
- Wash hands and surfaces often.
- Use separate cutting boards for foods.
- Thoroughly wash all fruits and vegetables before eating.
- Do not wash meat, poultry, or eggs to prevent spreading microorganisms to sink and other kitchen surfaces.
- Never use raw eggs in any form.
- Do not eat seafood raw or if it has an unpleasant odor
- Use a food thermometer to ensure cooking food to safe internal temperature.
- Keep food hot after cooking; maintain safe temperature of 140°F or above.
- Give only pasteurized fruit juices to small children
90
What are some methods of emptying the colon
- Enemas
- Rectal suppositories
- Oral intestinal lavage
- Digital removal of stool
91
What are the different types of bowel ostomies
- Sigmoid colostomy
- Descending colostomy
- Transverse colostomy
- Ascending colostomy
- Ileostomy
92
What are the energy supplying nutrients
Carbohydrates
Lipids
Proteins
93
Which nutrients regulate body processes
Vitamins
Minerals
Water
94
What is the basal metabolic rate
The energy required to sustain metabolic activities of cells and tissues
95
What is the primary source of heat in the body
Metabolism
96
What is the BMR in men vs. women
Men: 1 cal/kg/hr
Women: 0.9 cal/kg/hr
97
What are some factors that can raise BMR
- Growth
- infections
- fever
- emotional tension
- extreme environmental temperatures
- elevated levels of certain hormones
98
What are some factors that can lower BMR
- Aging
- prolonged fasting
- sleep
99
How do you calculate BMI
Weight (kg)/ (Height (m) x Height (m))
[ weight divided by height squared] [kg per meter squared]
100
What are the BMI categories
Underweight < 18.5
Normal (ideal) weight 18.5- 24.9
Overweight 25- 29.9
Obesity 30+
Waist circumference:
men: > 40 inches
women: >35 inches
101
What are carbohydrates
Organic compounds composed of carbon, hydrogen, and oxygen
Sugars and starches
Most abundant and cheapest source of calories
102
What are proteins
Made of amino acids
Required for the formation of all body structures
Complete and incomplete based on amino acid composition
103
What is considered a complete or incomplete protein
Complete: animal proteins
Incomplete: plant proteins
104
What is the recommended protein intake for an adult
0.8 g/kg of body weight
10% to 35% of total calorie intake
105
What are fats
Composed of carbon, hydrogen, and oxygen
Insoluble in water and blood
Saturated and unsaturated
106
What is the difference between saturated and unsaturated fats
Saturated: solid at room temp (most animal fats)
Unsaturated: liquid at room temp (most vegetable fats)
107
What types of food are consistent of trans fats
manufactured, partially hydrogenated oils
liquid at room temp
more stable = longer shelf life
108
Where are fats digested
Starts in mouth but mostly in the small intestine
109
What is the recommended saturated and trans fat intake for an adult
Saturated: <10% of calories/day
Trans: as little as possible (or none)/day
110
What are vitamins
Organic compounds needed by the body in small amounts
- Most are active in the form of coenzymes.
- Needed for metabolism of carbohydrates, protein, and fat
- Classified as water soluble or fat soluble
- Absorbed through the intestinal wall directly into
bloodstream
111
What are minerals
Organic elements found in all body fluids and tissues
- Some function to provide structure in the body,
- others help regulate body processes
- Contained in the ash that remains after digestion
- Macrominerals
- Microminerals
112
Which minerals are considered macrominerals
- calcium
- phosphorus (phosphates)
- sulfur (sulfate)
- sodium
- chloride
- potassium
- magnesium
113
Which minerals are considered microminerals
- iron
- zinc
- manganese
- chromium
- copper
- molybdenum
- selenium
- fluoride
- iodine
114
What percentage of the adult body weight consists of water
50-60%
2/3 of that water is inside cells
1/3 of that water is in extracellular fluid and plasma
115
What are some physiologic/physical factors affecting food habits
- stage of development
- state of health
- medications
116
What are some sociocultural/psychosocial factors affecting food habits
- Economics
- culture
- religion
- tradition
- education
- politics
- social status
- food ideology
117
What are some age related considerations causing differences in nutritional needs
Growth (infancy, adolescence, pregnancy, and lactation increase nutritional needs)
Activity increases nutritional needs.
Age-related changes in metabolism and body composition
Nutritional needs level off in adulthood because of decrease in BMR.
118
What are some risk factors of poor nutritional status
- Developmental factors
- Gender
- State of health
- Alcohol abuse
- Medications
- Megadoses of nutrient supplements
119
What are some potential complications of TPN
- Insertion problems
- Infection and sepsis
- Metabolic alterations
- Fluid, electrolyte, and acid–base imbalances
- Phlebitis
- Hyperlipidemia
- Liver and gallbladder disease
120
What are the nursing responsibilities when it comes to the nursing diagnosis
Recognize safety and infection transmission risks
Identify human responses
Anticipate possible complications
Initiate urgent interventions
121
What are the different types of diagnoses
Nursing diagnosis
medical diagnosis
collaborative problems
122
What is a nursing diagnosis
Patient problems that nurses can treat independently
123
What is a medical diagnosis
Problems for which the physician directs the primary treatment
124
What are collaborative problems
Managed by using physician-prescribed and nursing-prescribed interventions
125
What are the four steps of data interpretation and analysis
- Recognizing significant data: Comparing data to standards
- Recognizing patterns or clusters
- Identifying strengths, problems, and potential
complications
- Reaching conclusions
126
What are the four possible conclusions that can be reached after analyzing data
No problem
Possible problem
Actual or potential nursing diagnosis
Clinical problem other than nursing diagnosis
127
What does etiology mean
The cause of a disease or condition
128
What are the steps to forming the nursing diagnosis
1. identify the problem
2. etiology of the problem
3. defining characteristics of the problem
[problem] related to [etiology] as evidenced by [symptoms or characteristics]
Ex. [shortness of breath] r/t [smoking] AEB [use of accessory muscles and SPO2 of 88]
129
What are the three types of nursing diagnoses
problem-focused [problem etiology and evidence]
Risk [problem and etiology]
Health promotion
130
What are the goals of the outcome intervention/planning step of the nursing process
Establish priorities
Identify expected patient outcomes
Select evidence-based nursing interventions
Communicate the care plan
131
What are the three elements of comprehensive planning
Initial
Ongoing
Discharge
132
What does the initial planning step entail
- Developed by the nurse who performs the nursing history
and physical assessment
- Addresses each problem listed in the nursing diagnoses
- Identifies appropriate patient goals and related nursing care
133
What does the ongoing planning step entail
- Carried out by any nurse who interacts with patient
- Keeps the plan up to date, manages risk factors, promotes
function
- States nursing diagnoses more clearly
- Develops new diagnoses
- Makes outcomes more realistic and develops new outcomes
as needed
- Identifies nursing interventions to accomplish patient goals
134
What does the discharge planning step entail
- Carried out by the nurse who worked most closely with the
patient (usually a discharge planner)
- Begins when the patient is admitted for treatment
- Uses teaching and counseling skills effectively to ensure that
home care behaviors are performed competently
135
Nursing diagnosis priorities
High priority: greatest threat to patient well-being
Medium priority: nonthreatening diagnoses
Low priority: diagnoses not specifically related to current health problem
136
What are the steps in Maslow's hierarchy of needs
Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
137
What are the six aims of quality care established by the Institute of Medicine (IOM)
1. Safe: avoiding injury
2. Effective: avoiding overuse and underuse
3. Patient-centered: responding to patient preferences, needs,
and values
4. Timely: reducing waits and delays
5. Efficient: avoiding waste
6. Equitable: providing care that does not vary in quality to all
recipients
138
What are the three categories of outcomes
Cognitive (learning, education)
Psychomotor (new physical abilities)
Affective (self esteem)
139
What are the parts of a measurable outcome
Subject: The patient will...
Verb: walk, brush teeth...
Conditions: 20 ft., twice a day...
Performance criteria: SBA, without assistance...
Target time: short term or long term
Ex. The patient will walk 20ft SBA by the end of the week
140
What are the three types of nursing interventions
1. Nurse-initiated: actions performed by a nurse without a
physician’s order
2. Physician-initiated: actions initiated by a physician in
response to a medical diagnosis but carried out by a nurse
under doctor’s orders
3. Collaborative: treatments initiated by other providers and
carried out by a nurse
141
What is a procedure
A set of how-to action steps
142
What is standard of care
A description of the acceptable level of patient care
143
What is an algorithm
A set of steps used to make a decision
144
What is a clinical practice guideline
A statement outlining appropriate practice for clinical condition or procedure
145
What are some reasons for noncompliance
- Lack of family support
- Lack of understanding about the benefits
- Low value attached to outcomes
- Adverse physical or emotional effects of treatment
- Inability to afford treatment
- Limited access to treatment
146
What are the five rights of delegation
- Right task
- Right circumstances
- Right person
- Right directions and communication
- Right supervision and evaluation
147
What are SMART goals
S: specific
M: measurable
A: achievable
R: realistic
T: timely
148
What are the five elements of evaluation
1. Identifying evaluative criteria and standards
2. Collecting data to determine if criteria and standards are
met
3. Interpreting and summarizing findings
4. Documenting judgment
5. Terminating, continuing, or modifying the plan
149
What is evaluative criteria
Measurable qualities, attributes, or characteristics that specify skills, knowledge, or health status
150
What are standards when talking about evaluation
Levels of performance accepted and expected by the nursing staff
151
What are some variables that affect outcome achievement
Patient: gives up and refuses
Nurse: suffering from burnout
Health care system: inadequate staffing
152
What are some examples of an evaluative statement
Decide how well a goal was met along with data to support the statement
- met
- partially met
- not met
153
What are the six Quality and Safety Education for Nurses (QSEN) competencies
1. Patient-centered care
2. Teamwork and collaboration
3. Evidence-based practice
4. Quality improvement
5. Safety
6. Informatics
154
What are the different types of problem solving
- Trial-and-error problem solving
- Scientific problem solving
- Intuitive problem solving
- Critical thinking: intuitive, logical, or both
155
What are the five steps of the nursing process
ADPIE
1. Assessing
2. Diagnosing
3. Planning
4. Implementing
5. Evaluating
156
What does the diagnosis step of the nursing process entail
Analyzing patient data to identify patient strengths and problems
157
What does the planning step of the nursing process entail
Specifying patient outcomes and related nursing interventions
158
What does the implementation step of the nursing process entail
Carrying out the care plan
159
What does the evaluation step of the nursing process entail
Measuring extent to which patient achieved outcomes
160
What does the assessing step of the nursing process entail
Collecting, validating, and communicating patient data
161
What are the characteristics of the nursing process
- Systematic: part of an ordered sequence of activities
- Dynamic: great interaction and overlapping among the five
steps (ADPIE)
- Interpersonal: human being is always at the heart of nursing
- Outcome oriented: nurses and patients work together to
identify outcomes
- Universally applicable: a framework for all nursing activities
162
What are the steps of concept mapping
1. Collect patient problems and concerns on a list.
2. Connect and analyze the relationships.
3. Create a diagram.
4. Keep in mind key concepts: the nursing process, holism,
safety, and advocacy
163
What is concept mapping
An instructional strategy that requires learners to identify, graphically display, and link key concepts.
164
What are the types of reflective practice
Reflective in action
Reflective on action
Reflective for action
165
What does "reflective in action" mean
Happens in the here and now of the activity and is also known as “thinking on your feet”
166
What does "reflective on action" mean
Occurs after the fact and involves thinking through a situation that has occurred in the past
167
What does "reflective for action" mean
Helps the person to think about how future actions might change as a result of the reflection
168
What are the two clinical judgement models that we need to know for this class
1. Tanner's clinical judgement model
2. Nursing process
169
What is Tanner's clinical judgement theory
Research-based model
- noticing: initial grasp and perceptions of the situation
- interpreting: attributing meaning to the data
- responding: deciding on an action & monitoring outcomes
- reflecting: in-action and on-action
170
What are the four Clinical Decision-Making Theories, Models, and Frameworks
1. Humanistic–Intuitive Approach
2. Information-Processing Model
3. Cognitive Continuum Theory
4. Rest Framework
171
What is the Humanistic-Intuitive approach
Believes that clinical judgment and decision-making models move from facts and rules to dynamic decision making with clinical experience
172
What is the Information-Processing Model
Informs decision making and mirrors the way we think of a computer processor
173
What is the Cognitive Continuum Theory
Integrates both intuitive and analytical cognitive characteristics
174
What is the rest framework
Includes four components of moral reasoning and captures the cognitive processes that precede moral action
175
What are the five types of nursing assessments
1. Initial comprehensive
2. Focused
3. Emergency
4. Time-lapsed
5. Assessment of communities and special populations
176
What does an initial comprehensive assessment entail
Performed shortly after admittance to hospital
Performed to establish a complete database for problem identification and care planning
Performed by the nurse to collect data on all aspects of patient’s health
177
What does a focused assessment entail
May be performed during initial assessment or as routine ongoing data collection
Performed to gather data about a specific problem already identified, or to identify new or overlooked problems
Performed by the nurse to collect data about the specific problem
178
What does an emergency assessment entail
Performed when a physiologic or psychological crisis presents
Performed to identify life-threatening problems
Performed by the nurse to gather data about a life-threatening problem
179
What does a time-lapsed assessment entail
Performed to compare a patient’s current status to baseline data obtained earlier
Performed to reassess health status and make necessary revisions in care plan
Performed by the nurse to collect data about current health status of patient
180
What is the difference between medical and medical assessments
Medical assessments target data pointing to pathologic conditions
Nursing assessments focus on the patient’s response to health problems
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What is objective data
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
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What is subjective data
Information perceived only by the affected person
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What are some sources of data
- Patient
- Family and significant others
- Patient record
- Medical history, physical examination, progress notes
- Consultations
- Reports of laboratory and other diagnostic studies
- Reports of therapies by other health care professionals
- Nursing and other health care literature
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What are the four phases of the nursing interview
1. Preparatory phase: get report, look at EMR
2. Introduction: purpose of interview, their opinion, why they sought care
3. Working phase: ask questions, gather data
4. Termination: conclude the interview, update chart
