NURS301 day 4

Question 0

Foley

Answer 0

an in dwelling catheter

Question 1

Five steps of nursing process

Answer 1

Assessing—collecting, validating, and
communicating of patient data
Diagnosing—analyzing patient data to identify
patient strengths and problems
Planning—specifying patient outcomes and related
nursing interventions
Implementing—carrying out the plan of care
Evaluating—measuring extent to which patient
achieved outcomes

Question 2

The Nursing Process is used to:

Answer 2

Identify needs
Establish priorities of care
Maximize strengths
Resolve actual or potential alteration in responses to health and illness

Question 3

Name the five Characteristics of the Nursing Process

Answer 3

Systematic—part of an ordered sequence of activities

Dynamic—great interaction and overlapping among the five steps

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

Question 4

Benefits of the Nursing Process to the Patient (3)

Answer 4

• Scientifically based, holistic individualized patient care
• Continuity of care
• Clear, efficient, cost-effective plan of action

Question 5

Benefits of the Nursing Process to the Nurse (3)

Answer 5

• Opportunity to work collaboratively with other healthcare workers
• Satisfaction of making a difference in lives of patients
• Opportunity to grow professionally

Question 6

Intake (I’s)

Answer 6

Anything that the patient takes into the body.

Examples: foods they eat, liquids they drink, IV fluid that is being infused

Question 7

Output (o’s)

Answer 7

Anything that the patients releases from the body.

Examples: urine, stool, emesis (vomit)

Question 8

Why is it important to monitor the I’s and O’s?

Answer 8

*To keep track of a patient’s fluid balance.
Many diseases and medications can affect fluid balance

*Ensure that patient’s are meeting their caloric needs.
Conditions like wound healing require high amounts of dietary protein.

*Assess elimination status.
Enables the nurse to assess kidney function, GI function, and medication side effects

Question 9

Clear Liquid Diet

Answer 9

abdominal surgery type patients

Question 11

full liquid Diet

Answer 11

milk added to fluid like ice cream

Question 11

Cardiac Diet

Answer 11

salt reduction

Question 12

Puree diet

Answer 12

Patient cant chew

Question 13

Renal Diet

Answer 13

min sodium, phosphorous, and potassium, restrict fluid intake, adhere to ordered levels of protein and carbs. Goal of a renal diet is to cut down on waste in blood

Question 14

Diabetic Diet

Answer 14

no sugar

Question 15

Mechanical Soft Diet

Answer 15

pt may not have enough energy or teeth to chew all foods. The foods in this diet are easy to eat and do not need a lot of chewing to swallow safely.

Question 16

Although assisting with meals is commonly delegated to the nursing assistant, what must you be sure to do as the nurse?

Answer 16

It is your responsibility as the nurse to ensure that the patient is eating the appropriate diet and to assess and monitor for any potential complications

Question 17

Assisting with eating considerations (5)

Answer 17

Ensure that the food is an appropriate temperature, not too hot or cold.

Make sure the patient is positioned correctly to eat
Sitting upright in the bed or chair

Take your time! Make sure the patient has plenty of time to chew and swallow before providing more food.

Alternate solids and liquids.

Provide the appropriate amount of assistance based on patient needs.

Question 18

What are the goals associated with assisting with Eating?

Answer 18

Patient consumes adequate nutrition: 50-60% of meal tray is target

Avoid Aspiration!!

Patient expresses contentment-patient is full!

Question 19

Factors Affecting Urinary Elimination (6)

Answer 19

• aging (due to reduced muscle tone)
• Food and fluid intake
• Psychological conditions (nervousness)
• activity and muscle tone
• pathologic conditions (CHF, infections of urinary tract)
• medications

Question 20

Equipment used to assist with Elimination

Answer 20

bedpans, urinal, indwelling catheters, bedside commode

Question 21

Factors Affecting Bowel Elimination (4)

Answer 21

Mobility
diet
medications
intestinal diversion ex ostomies

Question 22

How often must you usually provide perianal care with an indwelling catheter?

Answer 22

every 12 hours and whenever a patient has a bowel movement

*remember to clean in a downward motion, away from the patient’s genitalia