foundations of nursing > quiz 5 > Flashcards
quiz 5 Flashcards
ICP
intracranial pressure
ICU
intensive care unit
ID
infectious disease
I&D
incision and drainage
IDDM
insulin dependent diabetes mellitus
IgE
immunoglobulin E
I&O
intake and output
IM
intramuscular
IMP
impression
INR
international normalized ratio
IS
incentive spirometry
IUD
intrauterine device
IV
intravenous
IVC
inferior vena cava
IVP
intravenous pyelogram
JCAHO
Joint Commission on Accreditation of Health Care Organizations
TJC
The Joint Commission
JP
Jackson Pratt
JVD
jugular vein distention
K
potassium
KCL
potassium chloride
kg
kilogram
KUB
kidney, ureter, bladder
KVO
keep vein open
L1 to L5
lumbar vertebrae, one to five
LDL
low density lipoprotein
LE
lower extremity
LLL
left lower lobe
LLQ
left lower quadrant
LMP
last menstrual period
LOC
level of consciousness
LOS
length of stay
LP
lumbar puncture
LPN/LVN
licensed practical nurse/licensed vocational nurse
LR
lactated ringers
LUL
left upper lobe
LUQ
left upper quadrant
LV
left ventricle
LVEF
left ventricle ejection fraction
assessing
systemic and continuous collection (throughout all phases of nursing process), organization, validation, and documentation of data
- types of assessments are the initial nursing assessment,
problem-focused assessment, emergency assessment, and
time-lapsed reassessment
- Nursing assessments focus on a client’s responses to a health problem. A nursing assessment should include the client’s perceived needs, health problems, related experience, health practices, values, and lifestyle
- within 24 hours of admission as an inpatient
database
contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider’s history and physical
examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
- include past history as well as current problems
ex. Past surgical procedures, folk healing practices, and chronic diseases
- subjective data (symptoms) & objective data (signs)
close-ended question
used in the directive interview, are restrictive and generally require only “yes” or “no” or short factual answers that provide specific information.
- begin with “when,” “where,” “who,” “what,” “do (did, does),” or
“is (are, was).”
- often used when information is needed quickly, such as in an emergency situation. Individuals who are highly stressed or have difficulty communicating will find closed questions easier to answer than open-ended questions
cues
subjective or objective data that can be directly observed by the nurse; that is, what the client says or what the nurse can see, hear, feel, smell, or measure.
leading question
usually closed, used in a directive interview, and thus directs the client’s answer.
- Examples are “You’re stressed about surgery tomorrow, aren’t you?” “You will take your medicine, won’t you?”
- leading question gives the client less opportunity to decide whether the answer is true or not. Leading questions create problems if the client, in an effort to please the nurse, gives inaccurate responses. This
can result in inaccurate data
neutral question
question the client can answer without direction or pressure from the nurse, is open ended, and is used in nondirective interviews.
- Examples are “How do you feel about that?” “What do you think led to the operation?”
open-ended question
associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.
- useful at the beginning of an interview or to change topics and to elicit attitudes
- may begin with “what” or “how.”
- Examples of open-ended questions are “How have
you been feeling lately?” “What brought you to the hospital?” “How did you feel in that situation?” “Would you describe more about how you relate to your child?” “What would you like to talk about today?”
symptoms
are apparent only to the individual affected and can be described or verified only by that individual.
- Itching, pain, and feelings of worry are examples of subjective data.
- include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation
- subjective data/covert data
signs
Objective data or overt data; are detectable by an observer or can be measured or tested against an accepted standard.
- can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination.
- For example, a discoloration of the skin or a blood pressure reading is objective data
- During the physical examination, the nurse obtains objective data to validate subjective data and to complete the assessment phase of the nursing process.
validation
act of “double-checking” or verifying
data to confirm that it is accurate and factual
- Validating data helps the nurse complete these tasks: Ensure that assessment information is complete, Ensure that objective and related subjective data agree, Obtain additional information that may have been overlooked, Differentiate between cues and inferences, Avoid jumping to conclusions and focusing in the wrong direction to identify problems.
- Not all data require validation. For example, data such as height, weight, birth date, and most laboratory studies that can be measured with an accurate scale can be accepted as factual.
- As a rule, the nurse validates data when there are discrepancies between data obtained in the nursing interview (subjective data) and the physical examination (objective data), or when the client’s statements vary at different times in the assessment.
actual diagnosis
also known as a problem-based diagnosis; this nursing diagnosis is a client problem that is present at the time of the nursing assessment.
- Examples are altered respiratory status or
impaired ability to cope.
- An actual or problem-based nursing diagnosis is based on the presence of associated signs and symptoms.
defining characteristics
the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
- For actual nursing diagnoses, the defining characteristics are the client’s signs and symptoms.
- For risk nursing diagnoses, no subjective and objective signs are present. Thus, the factors that cause the client to be more vulnerable to the problem form the etiology of a risk nursing diagnosis.
diagnosis
a statement or conclusion regarding the nature of a phenomenon.
etiology
causal relationship between the client’s problem or risk factors
health promotion diagnosis
relates to clients’ preparedness to implement behaviors to improve their health condition.
- these diagnosis labels begin with the phrase willingness to learn about the health maintenance or willingness to change health practices
nursing diagnosis
contains a diagnostic phrase or diagnostic label followed by an etiology phrase.
- nursing diagnoses are client problems that can be treated primarily by independent nursing interventions
- The diagnostic phrase or label is a statement of the client’s problem.
- The etiology is the causal relationship between the client’s problem or risk factors
risk nursing diagnosis
a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
- For example, all people admitted to a hospital have some possibility of acquiring an infection; however, a client with diabetes or a compromised immune system is at higher risk than others.
- Therefore, the nurse would appropriately use the label risk for or potential for impaired breathing patterns to describe the client’s health status.
syndrome diagnosis
clinical nursing judgement when a client has several similar nursing diagnoses such as impaired respiratory status related to increased secretions and restricted pulmonary airflow related to a lack of alveoli elasticity
collaborative interventions
actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, and primary care providers.
- Collaborative nursing activities reflect the overlapping responsibilities of, and collegial relationships among, health personnel.
- For example, the primary care provider might order physical therapy to teach the client crutch-walking. The nurse would be responsible for informing the physical therapy department and for coordinating the client’s care to include the physical therapy sessions. The nurse may assist with crutch-walking and collaborate with the physical therapist to evaluate the client’s progress.
concept map
a visual tool in which ideas or data are enclosed in circles
or boxes of some shape, and relationships between these
are indicated by connecting lines or arrows
dependent interventions
activities carried out under the orders or supervision of a licensed physician or other healthcare provider authorized to write orders to nurses.
- Primary care providers’ orders commonly direct the nurse to provide medications, intravenous therapy, diagnostic tests, treatments, diet, and activity.
desired outcome
in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions
- desired outcomes as the more specific, observable
criteria used to evaluate whether the goals have been met
- Desired outcome (specific): Gain 5 lb by April 25.
discharge planning
process of anticipating and planning for needs after discharge, is a crucial part of a comprehensive healthcare plan and should be addressed in each client’s care plan
- begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs
independent interventions
those activities that
nurses are licensed to initiate on the basis of their knowledge and skills.
- They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, and making
referrals to other healthcare professionals
- ex of independent action is planning and providing special mouth care for a client after diagnosing alteration in mucous membrane integrity
individualized care plan
tailored to meet the unique
needs of a specific client—needs that are not addressed by the standardized plan
- When nurses use the client’s nursing diagnoses
to develop goals and nursing interventions, the result is a holistic, individualized plan of care
multidisciplinary care plan
standardized plan that
outlines the care required for clients with common, predictable—usually medical—conditions
- also referred to as collaborative care plans and critical pathways, sequence the care that must be given on each day
during the projected length of stay for the specific type
of condition.
- nursing interventions + medical treatments to be performed by other healthcare providers as well.
- organized with a column for each day, listing the interventions that should be carried out and
the client outcomes that should be achieved on that day. There are as many columns on the multidisciplinary care
plan as the preset number of days allowed for the client’s diagnosis-related group (DRG)
nursing intervention
“any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes”
- required to prevent, reduce, or eliminate
the client’s health problems
priority setting
process of establishing a preferential sequence for addressing nursing diagnoses and interventions
- nurses can group them as having high, medium, or low priority. Life threatening problems, such as impaired respiratory or cardiac function, are designated as high priority. Health-threatening problems, such as acute illness and decreased coping ability, are assigned medium priority because they may result in delayed development or cause destructive physical or emotional changes.
A low-priority problem is one that arises from normal developmental needs or that requires only minimal nursing support.
- frequently use Maslow’s hierarchy of needs
when setting priorities; physiologic needs such as air, food, and water are basic to life and receive higher priority than the need for security or activity
- the nurse often deals with
more than one diagnosis at a time.
- must consider client’s health values/beliefs, priorities, resources available, urgency of health problem and medical treatment plan
policies and procedures
developed to govern the
handling of frequently occurring situations.
- For example, a hospital may have a policy specifying the number of visitors a client may have. Some policies and procedures are similar to protocols and specify what is to be done, for example, in the case of cardiac arrest
- Policies are institutional records and do
not become a part of the care plan or permanent record
protocols
predeveloped to indicate the actions commonly required for a particular group of clients.
- For example, an agency may have a protocol for admitting a client to the intensive care unit or for caring for a client receiving continuous epidural analgesia
- may include both the primary care provider’s orders and nursing interventions. Depending on the agency, protocols may or may not be included in the client’s permanent record
standardized care plan
formal plan that specifies the nursing care for groups of clients with common
needs (e.g., all clients with myocardial infarction).
-use the formal care plan for direction about
what needs to be documented in client progress notes and
as a guide for delegating and assigning staff to care for clients
standing order
written document about policies, rules, regulations, or orders regarding client care
- give nurses the authority to carry out specific actions under certain circumstances, often
when a primary care provider is not immediately available
- a common example is the administration of emergency antiarrhythmic
medications when a client’s cardiac monitoring pattern
changes.
audit
examination or review of records
- retrospective audit is the evaluation of a client’s record after discharge from an agency
- concurrent audit is the evaluation of a client’s healthcare while the client is still receiving
care from the agency
- use interviewing,
direct observation of nursing care, and review of clinical records to determine whether specific evaluative criteria
have been met.
quality improvement
follows client care rather than organizational structure, focuses on process rather than individuals, and uses a systematic approach with the intention of improving the quality of care rather than ensuring the quality of care.
- Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of healthcare systems”
- one of the six competencies in the Quality and Safety Education for Nurses
root cause analysis
process for identifying the factors that bring about deviations in practices that lead to the event.
- It focuses primarily on systems and processes, not individual performance.
- It begins with examination of the single event with the
purpose of determining which organizational improvements are needed to decrease the likelihood of such events
occurring again
sentinel event
an unexpected occurrence involving death, permanent harm, or severe temporary harm and intervention required to sustain life
- provide the impetus for immediate investigation as to the cause and determine the appropriate response.
- The Joint Commission has developed sentinel event policies for all
types of agencies that are accredited by the Joint Commission.
