NRSG200 > 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 extemity
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
the systematic and continuous collection, organization, validation, and documentation of data. carried out during all phases of the nursing process. ex: in the evaluation phase, client is reassessed to determine outcomes of the nursing strategies and to evaluate goal achievement. four different types of assessment: initial nursing assessment, problem-focused assessment, emergency assessment, time-lapsed reassessment.
assessment type varies by purpose, timing, time available, client status.
assessing includes: making reliable observations, validating data, organizing data, etc
database
contains all the information about a client; it includes 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.
ex: hx of an allergic rxn to penicillin is vital piece of historical data. also past surgeries, folk healing practices, chronic diseases, pain, nausea, sleep patterns, religious practices.
data can be subjective or objective and constant or variable, from a primary or secondary source.
close-ended question
used in the directive interview, are restrictive and generally require only yes / no or short factual answers that provide specific info. often begin with “when/where/who/what/do(did/does)/is(are/was)”. Ex: what med do you take? how old are you?
closed questions often used when info is needed quickly ie in emergencies. highly stressed person & ppl with diff communicating will find closed questions easier to answer
cues
subjective or objective data that can be directly observed by the nurse; what the client says or what the nurse can see, hear, feel, smell, or measure.
leading question
usually closed question, used in directive interview. directs the client’s answer. ex: you’re stressed about surgery tomorrow, aren’t you?
gives the client less opportunity to decide whether the answer is true or not. create problems if the client, in effort to please the nurse, gives inaccurate responses»_space;> 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. ex: how do you feel about that? or what do you think led to the operation?
open-ended question
associated with the nondirective interview. invites clients to discover, explore, elaborate, clarify, illustrate thoughts/feelings. open question specifies only the broad topic to be discussed, invites answers longer than one-two words. gives clients freedom to divulge only info they are ready to. useful at beginning of interview/to change topics & elicit attitudes.
begin with what/how. ex: “how did you feel in that situation?” “what would you like to talk about today?”
symptoms
subjective data aka covert data, apparent only to the person affected and can be described or verified only by that person. ex: itching, pain, feelings of worry. (sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situation)
signs
aka objective data aka overt data. detectable by an observer or can be measured or tested against an accepted standard. can be seen, heard, felt, smelled, and are obtained by observation or physical exam. ex: discoloration of skin or BP reading are objective data. during phys exam, nurse obtains objective data to validate subjective data and to complete the assessment phase of nursing process.
validation
act of double-checking or verifying data to confirm that it is accurate and factual. validating data helps nurse complete these tasks:
- ensure assessment info is complete
- ensure obejctive/related subjective data agree
- obtain additional info that may have been overlooked
- differentiate btwn cues/inferences
- avoid jumping to conclusions/focusing in wrong direction
- not all data require validation. ex: data like height, weight, birthday, most labs can be accepted as factual.
actual diagnosis
client problem that is present at the time of the nursing assessment. ex: Ineffective Breathing Pattern, Anxiety.
actual nursing diagnosis is based on presence of associated signs/symptoms.
defining characteristics
the cluster of signs/symptoms that indicate the presence of particular diagnostic label. for actual nursing dx: defining characteristics = signs/symptoms. for risk nursing dx, no subjective/objective signs are present.
diagnosis
a statement or conclusion regarding the nature of a phenomenon.
etiology
causal relationship between a problem and its related 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 Readiness for Enhanced, as in Readiness for Enhanced Nutrition.
nursing diagnosis
standardized NANDA names for the diagnoses (diagnostic labels) plus the client’s problem statement, consisting of diagnostic label and etiology, is a nursing diagnosis.
three components: problem and its definition, etiology, defining characteristics
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.
ex: all people admitted to hospital have some possibility of acquiring infection: however, client with diabetes or compromised immune system is at higher risk than others. therefore, nurse would use label Risk for Infection to describe health status.
syndrome diagnosis
assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions.
collaborative interventions
actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, primary care providers.
ex: nurse may assist with crutch-walking and collaborate with the physical therapist to evaluate client 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. they are creative endeavors. they can take many diff forms and encompass various categories of data. used to depict complex relationships among ideas, processes, actions, etc. some are aka mind maps. can create concept maps for linkages among diseases, lab data, meds, signs, symptoms, risk factors, etc
dependent interventions
activities carried out under orders/supervision of licensed physician or other health care provider authorized to write orders to nurses. primary care providers orders commonly direct nurse to provide meds, IV therapy, diagnostic tests, treatment, activity, diet. ex: for a medical order of “Progressive ambulation, as tolerated”nurse could write “dangle for 5 mins, 12 hours postop. stand at bedside 24 hours postop. observe for pallor, dizziness. check pulse before and after ambulating. do not progress if pulse is greater than 110.”
desired outcome
fillfill
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discharge planning
process of anticipating and planning for needs after discharge. a crucial part of comprehensive health care plan, should be addressed in each client’s care plan. effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain info about client’s ongoing needs
independent interventions
those activities that nurses are licensed to initiate on the basis of their knowledge and skills. include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management, making referrals.
ex: planning and providing special mouth care for client after diagnosing Impaired Oral Mucous Membranes
individualized care plan
tailored to meet the unique needs of a specific client-needs that are not addressed by standardized plan.
multidisciplinary care plan
a standardized plan that outlines the care required for clients with common, predictable-usually medical-conditions. aka collaborative care plans or critical pathways. they sequence the care that must be given on each day during projected length of stay for specific type of condition. like traditional care plan, includes outcomes/nursing interventions/nursing diagnoses. however, it also includes medical treatments to be performed by other healthcare providers as well.
usually organized by column for each day.
nursing intervention
any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.
priority setting
process of establishing a preferential sequence for addressing nursing diagnoses and interventions. nurse and client begin planning by deciding which nursing diagnosis requires attention first, second, so on. can group them as high, medium, or low priority instead of ranking them.
life threatening probs ie impaired respiratory/cardiac fx = high priority.
health threat problems ie actue illness/decreased coping ability = medium priority
problem that arises from normal developmental needs or requires only minimal nursing support = low priority.
frequently use Maslow’s hierarchy of needs for priority setting.
for maslows: physiological needs for air, food, water are higher priority than need for security/activity.
policies and procedures
developed to govern handling of frequently occurring situations. ex: hospital may have policy specifying the number of visitors a client may have. some are similar to protocols and specify what is to be done. ex: in case of cardiac arrest
protocols
predeveloped to indicate the actions commonly required for a particular group of clients. ex: agency may have protocol for admitting client to ICU or for caring for client receiving continuous epidural analgesia. include both primary care provider’s orders and nursing interventions. may or may not be included in client’s permanent record.
standardized care plan
formal plan that specifies the nursing care for groups of clients with common needs (eg all clients with myocardial infarction)
standing order
a written document about policies, rules, regulations, 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.
ex: administration of emergency antiarrhythmic meds when client’s cardiac monitoring pattern changes. or a standing order for nurse to obtain blood tests for client who has been on a certain therapy for a prescribed amount of time.
audit
refers to the examination or review of records.
retrospective audit: evaluation of client’s record after discharge
concurrent audit: evaluation of client’s health care while client is still receiving care from agency. these use interviewing, direct observation of nursing care, review of clinical records to determine whether specific evaluative criteria have been met.
quality improvement
(QI) aka continuous quality improvement (CQI) aka total quality management (TQM) aka performance improvement (PI) aka persistent quality improvement (PQI).
follows client care rather than organizational structure, focuses on process rather than the individuals, and uses systematic approach with the intention of improving quality of care rather than ensuring the quality of care. QI studies often focus on identifying and correcting system problems, like duplication of services in a hospital.
is one of the six competencies in Quality and Safety Education for Nurses (QSEN) project. they define as: use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve quality and safety of health care systems.
root cause analysis
a process for identifying the factors that bring about deviations in practices that lead to the event. focuses primarily on systems and processes, not individual performance. begins with exam of single event but with purpose of determining which organizational improvements are needed to decrease the likelihood of such events occurring again.
sentinel event
an unexpected occurrence involving death/serious physical or psychological injury, or risk thereof. serious injury specifically includes loss of limb or function.
called sentinel because they signal the need for immediate investigation and response.
