Nursing Process/Check In Flashcards
What are the steps of nursing process
Assessment Diagnosis Outcome identification & planning Implementation Evaluation
Assumptions with patient centered care?
Active partnership Patient autonomy Shared responsibility Respect privacy and decision making Sharing information Culturally aware of beliefs / other factors that may influence patient Pt advocacy Respecting all cultural, racial, ethnic, gender and sexual orientation Aware of health literacy/language levels
Why is patient engagement important?
Patient centered
Foundation for patient quality and safety
What is covered in a complete assessment?
All systems including: Cultural Emotional Spiritual Developmental Lifestyle aspects SDOH
What is covered in a focused assessment?
Data collection required for specific health issue
Conducted when patient is unable to participate ex. Disorientated
Performed continually during nurse - patient contact
Who was the first to incorporate nursing diagnosis into nursing process?
American Nurses Association
Outcome part of nursing process?
Collaborate with patient to determine expected outcomes
Planning part of nursing process?
Nurse establishes priorities of care
Chooses nursing intervention
What is NANDA-I?
North American nursing diagnosis association
International
TJC focused assessment. 5 W’s?
Who - correct patient What - correct procedure, consent When - when is procedure? 2 at once? Where - correct site, marked, consent Why - purpose of surgery
What are you checking in patients chart in check in?
Consent H&P Vital signs Allergies Diagnostic tests NPO status Doctors orders -abx Nurses notes - info/concerns about pt Confirming implants, prosthesis, deformities or disease processes that require special consideration for surgery
Meeting a patient considerations?
2 identifiers
How would they like to be addressed
Never assume family relationships
Determine NPO status, last void, prep done
Confirm procedure, site, how it will be done
Consent - confirming signatures/blood consent
What are patients concerns pre op?
Fear of unknown Giving control to others Being awake during surgery Not waking up after anesthesia Surgery concerns - pain, prognosis
Affects of pre - op anxiety?
Affect surgical outcomes
- increase anesthetic doses
- HTN - increased bleeding, N/V
- increased risk for SSI’s
Affects of anxiety on the body?
Brain - depression, irritability Immune system - decrease in function Skin - delayed healing Cardio - HTN Gut - malabsorption Joints - pain, stiffness Reproductive- decreased libido
Suicide mentioned in assessment?
Report immediately
Follow P&Ps
Pain assessment?
Always use same pain scale
Positioning considerations
Geriatric, obese, paediatric
- issues with shoulders, hips, knees
- extra precautions
Pre procedure check in checklist?
Identify patient Allergies Procedure/site Consent Site marked H&P Pre anesthesia assessment Diagnostic testing Blood products Special equipment/devices/implants Beta blocker meds VTE prophylaxis Normothermia measures
Medications/ food/ supplemental therapies considerations for surgery?
Review all meds prescribed and OTC in pre op assessment
Can have impact on procedure and potentially cause adverse effects when combined with anesthesia
Cannabis considerations?
Unknown affects to tolerance of anesthetic agents
Metabolized by liver and excreted through feces, bile and urine
Cannabis affects on body?
CNS - sedative, anxiety, dizzy
Cardio - vasodilator, tachycardia
Pulmonary - airway edema, bronchodilation
GI - increased appetite, nausea
Why is cannabis risk factor for surgery?
Hyperactive airway Anxiety Unknown tolerance to induction agents Unknown tolerance to pain meds Withdrawl
ETOH risks with surgery?
Lowered immunity
Prolonged bleeding
Increased stress response
Cardiac complications
Intra op hypothermia may cause?
Poor healing
Increased post op pain
Pressure injuries
Decreased drug metabolism
Risk factors for hypothermia?
Low body weight Paediatric/ geriatric Thyroid disorders PVD Diabetic neuropathy Open cavity surgeries
Active warming measures?
Forced air warming
Increased room temp
Warmed IV fluids
Passive warming measures?
Thermal clothing
Warm cotton blankets
Reflective material
VTE prophylaxis?
Mechanical / pharmaceutical
- SDCs, anticoagulant
Patient risk factors for VTE?
> 40yrs old Obese Hx of VTE Bedrest > 3 days Varicose veins CVC Smoking Dehydration OSA Pregnancy
Procedure risk factors for VTE?
> 90min long Positioning Tourniquet use Transplant surgery Emergency surgery Concurrent surgeries Open surgery
VTE meds?
Anticoagulant
Thrombolytic
Factor Xa inhibitors
Thrombin inhibitors
How long should you stop VTE medications prior to surgery?
48hrs prior
Patient sign in checks?
Correct patient Correct procedure Correct site & site marking Consent Allergies Pulse ox on Is patient aspiration risk or difficult airway - cart in room? Risk of blood loss > 500mL - blood been ordered?
Pre op assessment interview?
Physiological status Body size Mobility Pre existing health conditions Planned duration of procedure Type of anesthesia
