PRE-CLINICAL Flashcards
Potentially life threatening and require
immediate actions
HIGH PRIORITY
Something that needs immediate attention
HIGH PRIORITY
Involve problems that could result in unhealthy consequences such as physical and emotional impairment but not likely to
threaten life.
MEDIUM PRIORITY
Problem will be easily resolved
LOW PRIORITY
A clinical judgment concerning an undesirable human response to health condition/life process that exists in an individual, family or community.
PROBLEM-FOCUSED DIAGNOSIS
A clinical judgment concerning the susceptibility of an individual, family or community for developing an undesirable human response to health condition/life
processes
RISK DIAGNOSIS
A clinical judgment concerning motivation
and desire to increase well-being and to
actualize health potential.
HEALTH PROMOTION DIAGNOSIS
Responses are expressed by a readiness to enhance specific health behavior and can be used in any health state.
HEALTH PROMOTION DIAGNOSIS
Observable cues/inferences that cluster as
manifestations of a diagnosis (e.g., signs and symptoms)
DEFINING CHARACTERISTICS
An integral component of all problem
focused diagnosis
RELATED FACTORS
Etiologies, circumstances, facts, or
influences that have some type of
relationship with the nursing diagnosis
RELATED FACTORS
The formulation of goals and measurable that provides the basis for evaluating nursing diagnosis. – (ANA, 2014)
OUTCOME IDENTIFICATION
an educated guess, made as a board statement about what that patient’s state will be after the nursing intervention is completed. It directly addresses the problem stated in the nursing diagnosis
PATIENT OUTCOME
can be met in a relatively short period (within days or less than 1 week)
SHORT TERM OUTCOME
requires more time (perhaps several weeks
or months).
LONG TERM OUTCOME
Usually describe expected benefits or results that are seen after the plan of care has been implemented.
LONG TERM OUTCOME
Specific, measurable, realistic statements
of goal attainment
OUTCOME CRITERIA
Present information that will guide the
evaluation phase of the nursing process
OUTCOME CRITERIA
Answers the questions who, what actions,
under what circumstances, how well and when
OUTCOME CRITERIA
Development of nursing strategies designed to ameliorate patient problems
PLANNING
IMPLEMENTATION SKILLS NEEDED:
Intellectual skills
Interpersonal skills
Technical skills
- The sixth phase
- The judgment of the effectiveness of
nursing care to meet patient goals based on patient’s responses
EVALUATION
Refers to the transfer of professional responsibility and accountability for some all aspect of care for a patient, or group patients, to another person or professional group on a temporary or permanent basis.
CLINICAL HANDOVER/ ENDORSEMENT
may be facilitated by a large group with all
nurses commencing the shift and/or within smaller groups of nurses working together
GROUP HANDOVER
direct patient handover that occurs at the patient’s bedside and includes patients and parents/watcher
BEDSIDE HANDOVER
occurs between the nurses that hold
responsibility for care and the nurse who will be assuming responsibility for the care of the patient.
BREAK HANDOVER
(for procedure, treatment or to another ward) – all patients transferred to one clinical area to another clinical area require
handover to be documented. This includes details of transfer time indicating transfer of professional responsibility and accountability.
TRANSFER OF PATIENT
Patient care record in a form of checklist (not used in SPH, used only in certain areas like the ICU)
FLOW SHEET
most familiar type of documentation, summarizing the event of care in a chronological order like the patient’s status, treatments, and responses; used in SPH
NARRATIVE
problem-oriented type of documentation wherein the nurse finds certain problem of the patient during time of the shift and list it down like NCP
SOAP/SOAPIE/SOAPIER
intended to make the clients concern and strengths as the focus
FDAR
Clinical measurements that indicates the state of the patient’s essential functions such as the temperature, pulse rate, respiration rate, and blood pressure.
VITAL SIGNS
It reflects the body’s physiological status and its ability to regulate temperature, maintain local and systemic blood flow, and oxygenate tissues.
VITAL SIGNS
diff. between the heat produced and heat loss in the body with the use of a thermometer.
TEMPERATURE
number the heart beats per minute as the heart pumps blood to arteries causing them to expand and contract.
PULSE RATE
number of breath a person makes per minute as oxygen and carbon dioxide exchange inside the body.
RESPIRATORY RATE
measure of pressure exerted by the blood as it flows through the arteries.
BLOOD PRESSURE
is usually seen in the station for documentation of vital signs in all patients in the ward/ area without needing to see the chart
VITAL SIGNS MASTERLIST
also seen usually in the station, that aside from writing on the vital signs taken, the frequency of urination and defecation can be seen readily in the sheet
TPR SHEET
we also term this as the TPR graphic chart. In this sheet, the progress of the vital signs recorded can be seen right away through the plotting done in it. It is usually seen attached in the patient’s chart.
GRAPHIC CHART
vital signs documentation in tabulated form and is usually found in the patient’s chart.
VITAL SIGN SHEET
documentation of vital signs in a narrative form along with the nurse’s notes.
NURSES NOTES
The aseptic administration of delivering fluids, electrolyte, nutrients, and medications that are given via the venous route
INTRAVENOUS THERAPY
- having the same concentration of solutes as blood plasma
- remain inside the intravascular
compartment, thus expanding it
ISOTONIC FLUIDS
- Lesser concentration of solutes
- Dilutes the serum, which decreases serum osmolarity
- Solutes enter the cells, causing swelling of
cells
HYPOTONIC FLUIDS
- has a greater concentration of solutes
- Pulls fluid and electrolytes from the
intracellular and interstitial compartments into the intravascular compartment - Fluid exits the cells, causing cells to shrink
HYPERTONIC FLUIDS
○ 0.9% NaCl (PNSS)
○ Lactated Ringer’s (PLR)/ Plain Lactated
Ringer’s
○ 5% Dextrose in Water (D5W)
ISOTONIC SOLUTIONS
○ 0.45% NaCl
○ 0.33% NaCl
○ 0.225% NaCl
○ 2.5% Dextrose in Water
HYPOTONIC SOLUTIONS
○ 5% Dextrose in normal saline (D5NSS)
(Yellow)
○ 5% Dextrose in 0.45% NaCl (D5 1⁄2 NSS)
○ 5% Dextrose in Lactated Ringer’s (D5LR)
(Pink)
○ 10-50% Dextrose in Water
HYPERTONIC SOLUTIONS
Contains some CHO
(carbohydrate which consists of C-carbon,
H-hydrogen, and O- oxygen) and H20
● Useful in preventing dehydration
● Insufficient calories
NUTRIENT
- contains varying number of
cations and anions
ELECTROLYTE
used to increase the blood volume following severe blood loss or loss of plasma
VOLUME EXPANDERS
TYPES OF INFUSION
- Continuous Infusion
- Intermittent Infusion
- Bolus
- Piggyback/Secondary Infusion
–These are small gauge needles. The needles have plastic wings on the shaft to facilitate placement.
BUTTERFLY NEEDLES
T OR F: butterfly needles should only be
used for IV infusions of five hours or less
EURT
A collection of sterile devices designed to conduct fluids from an intravenous (IV) fluid container to a patient’s venous system; used for gravitational intravenous administration.
INFUSION SET
spike that allows large volumes of fluid to flow from a bag into a collecting chamber and then into a patient, who requires rapid fluid resuscitation
MACRODRIP
Tubing is narrower and so produces smaller drops. It is used for children and infants, or to infuse sensitive medications
where precision in the flow rate is essential
MICRODRIP
delivers specifically measured volumes
MEASURED VOLUME SET
– A device for monitoring intravenous infusions. The Device may have an alarm in
case the flow is restricted because of an occlusion of the line. In that case, the alarm will sound when a preset pressure limit is sensed.
ELECTROMECHANICAL INFUSION DEVICE
– occurs from the entry of microorganisms into the body through venipuncture
INFECTION
Redness, swelling and drainage at
the IV
S/sx of infection
Nursing management for Infection
strict aseptic technique, monitor signs of systemic infection, discontinue IV
occurs when IV fluid or medications leak into the surrounding tissue. It can be caused by improper placement or dislodgement of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel.
INFILTRATION
Cause:
Cannula dislodgement or perforation of wall of vein.
INFILTRATION
●S/sx of infiltration
leakage of IV fluid, discomfort, fluid
flow
Nursing Management of Infiltration
Stop infusion & remove cannula, elevate limb, apply warm or cold compressors
Using appropriate size & type of cannula & a good fixation technique prevents this problem
It is similar to infiltration, with an advertent administration of vesicant solution or medication into the surrounding tissue that leads to blisters inflammation necrosis of tissue e.g. chemotherapeutic agents, dopamine, calcium preparations
EXTRAVASATION
Signs and symptoms of Extravasation
leakage of IV fluid, discomfort, fluid
flow
Nursing Management of Extravasation
Use of antidote according to the policy, throughout neurovascular assessment of affected extremity must be performed frequently
- Inflammation of a vein related to a chemical or mechanical irritation or both.
PHLEBITIS
Underlying cause of Phlebitis
Risk of Phlebitis increases with the length of time IV line is in place, site of cannula inserted, microorganism at the time of insertion
S/sx: redness, warm area, pain, tenderness
PHLEBITIS
Nursing Management for Phlebitis
Discontinue the IV, Apply cold compress (later on warm compress), keep the site
elevated
To avoid phlebitis, use strict aseptic
techniques, rotate IV site every 72 hours
as per policy or as needed. Daily dress
the site or as needed.
Measured in mL
INTAKE AND OUTPUT
● Fluids that go IN the body
● Fluids taken via mouth, tube feedings,
and IV
● Water, juice, soup
● Parenteral (through IV)
● Irrigants
INTAKE
● Fluids that come OUT of the body
● Insensible loss
● Not easily measured
● E.g. Loss from sweating and
evaporation
● Urine, drainage, vomitus, bleeding
● Stool
OUTPUT
Percentage of water in the human body:
FETUS
90%
Percentage of water in the human body:
NEWBORN
80%
Percentage of water in the human body:
CHILD
90%
Percentage of water in the human body:
ADULT
90%
Percentage of water in the human body:
ELDERLY
90%
Output > Intake
AT RISK FOR DEHYDRATION
Intake > Output =
AT RISK FOR FLUID OVERLOAD
What type of nursing diagnosis is present at the time of the assessment ?
PROBLEM-FOCUSED DIAGNOSIS
What tool do we use in priotizing nursing
problems ?
MASLOW’S HIERARCHY OF NEEDS
Used to diagnose and differentiate one
diagnosis from another
● DEFINING CHARACTERISTICS
● RELATED FACTORS
● RISK FACTORS
Give the third step in making an assessment
● VERIFY , VALIDATE, AND DOUBLE
CHECK DATA
What are the 3 implementation skills
needed?
Answer:
INTELLECTUAL SKILLS,
INTERPERSONAL SKILLS,
TECHNICAL SKILLS
It is a clinical judgement concerning the
susceptibility of an individual , family or
community for developing an undesirable
human response to a health condition.
RISK DIAGNOSIS
What type of nursing diagnosis is “ Ineffective airway clearance related to
consolidation as evidenced by wheezing
upon auscultation”?
PROBLEM-FOCUSED DIAGNOSIS
A data consists of opinion and perception
rather than fact
SUBJECTIVE DATA
Low priority problems are potentially life
threatening and require immediate action.
FALSE
T OR F: Data from significant others and other health professionals may also be objective if they consist of opinion and perception rather than fact.
FALSE
Give one (1) way to collect data or assessment to the patient.
● INTERVIEW
● HEAD TO TOE ASSESSMENT
● PHYSICAL ASSESSMENT
● OBSERVATION
T OR F: Immediate life-threatening problems are a medium-priority problem.
FALSE
T OR F: Is “8/10 score on the pain scale” 0/1 an objective cue?
FALSE
T OR F: Evaluation is the sixth and the last phase of the nursing process?
TRUE
