Test 1 Flashcards
performing nursing interventions to promote, maintain, or restore client health
Implementation
nurse utilizes the client’s assessment data to identify nursing interventions which will achieve measurable client goals/outcomes
Planning
The nurse identifies patterns or trends, compares the data with expected standards or reference ranges and draws conclusions to direct nursing care
Analysis
the application of nursing knowledge to the collection, organization, validation, and documentation of data about a client’s health status and needs
Assessment
Assessment of a clients response to nursing interventions and determination if outcome goals were met or if additional planning is required
Evaluation
step of the nursing process in which the nurse collects organize and validates data by using critical thinking skills
assesment
are based on facts measurable and what the nurse can observe or notice by using senses ex. vital signs
objective data
are derived from the clients self report or from a family member ex. pain a patient feels
subjective data
RN reviews the client’s assessment findings to determine the clients problems and formulates a plan of care
analysis
RN makes plans to address the client’s problems by formulating individualized interventions and goals is to ensure the client achieves a positive outcome
Planning
involves taking action to provide nursing care as outlined
Implementation
RN views the effectiveness of the interventions provided and documents the clients response
Evaluation
mental process used when analyzing all the data pertaining to a clinical situation and making decision based on that analysis
Clinical reasoning
is the clinical reasoning across an expanse of time
Clinical Judgement
What is maslows hierachy of needs (1)?
physiological needs
What is maslows hierachy of needs (2)
safety needs
What is maslows hierachy of needs (3)
love and belonging
What is maslows hierachy of needs (4)
Esteem
What is maslows hierachy of needs (5)
self actualization
focuses on decreasing the risk for development of medical conditions by changing behaviors or minimizing exposures ex. vaccinations, lifestyle changes
primary prevention
consists of early screening to detect a disease process before it progresses to cause symptoms or complications in the client ex. screening test
secondary prevention
focuses on controlling the chronic effects of a health issue that has already occured and on restoring the individual optimal functioning e. education about self care
tertiary prevention
a positive state of mind comprising the actions taken by individuals to achieve their fullest potential for complete holistic health
wellness
is the response of a person to a disease; its is a process in which the person’s level of functioning is change when compared with a previous level
illness
is a state of complete physical mental and social well being
health
views health as a constantly changing state with high level wellness and death at opposite end of a graduated scale
wellness continuum
the cancer screening nemonic
CAUTION
abnormally low count of RBCs, hemoglobin concentrations, sometimes both, diminished O2 carrying capacity
Anemia
What are the lab tests done for Anemia?
CBC count, RBC indices, sickle cell tests
conditions in the environment in which people are born in and learn work pay worship and age that affect a wide range of health functioning and quality of life outcomes and risks
social determinants of health
is the amount of blood supplied to an area
perfusion
what is normal pulse rate
60-100 bpm
increased heart rate
tachycardia
what is the rate for tachycardia?
100-180 bpm
slower heart rate
bradycardia
what is the rate for bradycardia
pulse rate below 60 bpm
quality of pulse in terms of its fullness and reflects the strength of left ventricular contraction
pulse amplitude
the pattern of the beats and pauses between them
pulse rhythm
irregular heartbeat pattern
dysrhythmia
what is a normal BP amount
below 120/80mmHg
what is the hypotension rate?
90/60 mmHg
Is BP above normal rate for a sustained period
hypertension
what is the hypertension rate?
130/80mmHg or higher
difficult or labored breathing
dyspnea
What is a healthy adult breath/min
12 to 20 breath/min
What is the 3 step to the sick role?
Assuming dependent role
What is stage 1 of the sick role
Expiriencing symptoms
What is the second step of the sick role?
Assuming sick role
what is senior 65+ breathing rate?
16- 24 breaths/min
Rapid breathing
Tachypnea
increased rate and depth of ventilation above the body’s normal metabolic requirements
hyperventilation
slow breathing
Bradypnea
inadequate o2 to the body decrease in gas exchange
Hypoxia
heard over the larynx and trachea are high pitched harsh blowing sounds with sound on expiration being longer than inspiration
Bronchial breath sounds
are heard over mainstem bronchus and are moderate blowing sounds with inspiration equal to expiration
Bronchovesicular
are soft low pitched whispering sounds heard over most of the lungs fields with sound on inspiration longer than expiration
vesicular breath sounds
abnormal sounds are normally heard in the lungs and result from air moving through moisture, mucus or narrow airways
adventitious breath sounds
frequently heard on inspiration are soft high pitched discontinuous popping sounds
crackles
are continous musical sounds produced as air passes through airways constricted by swelling, narrowing secretions ir tumors
wheezes
continous gurgling or bubling sounds
Rhonchi
different breathing techniques
deep breathing
using incentive spirometry
pursed lip breathing
diaphragmatic breathing
