Week Ten Flashcards
Exam Four
Define Evidence Based Practice
The formulation of treatment decisions by using the best available research evidence and integrating this evidence with the practitioner’s skill and experience
Purpose of Nursing Care Plan
Describes routine care to meet basic needs, addresses nursing diagnosis and collaborative problems, specific nursing responsibilities in carrying out the plan of care, must include the client if the plan is to be effective, incorporates client values, beliefs, and preferences, encourages active participation from client/caregivers/family
Essential Components of nursing interventions
what, when, how
What is the criteria for therapeutic nursing interventions?
safe, appropriate, achievable, belief/value sensitive, not contraindicated, based on nursing knowledge, within established standards of care, appropriate cognitive, interpersonal and psychomotor skills
Dependent TNI
Physician initiated. Activities that are carried out under the physician’s orders or supervision, or according to specified routes. Ex. Med administration
Independent TNI
Nurse Initiated. Activities a nurse may initiate on the basis of their licensure, knowledge and skills. Ex. Assessing stool consistency
Collaborative TNI
Collaborative actions the nurse carries out with other health team members. Reflect overlapping responsibilities and collegial relationships.
How are TNIs prioritized?
Maslow’s hierarchy, high priority, intermediate priority, low priority
High Priority
Life threatening
Intermediate priority
Health Threatening
Low Priority
normal development, minimal nursing support
Types of TNIs
observations/assessments, prevention strategies, treatments, health promotion
Steps in Implementation
reassessing client, determining need for assistance, implementing nursing strategies, communicate/document nursing actions
Reassessing Client
Is intervention still needed? Are priorities still correct?
Determining need for assistance
Perform safely alone? Knowledge/skills?
Implementing nursing strategies
explain rationale, evidenced based practice, do I understand the interventions? are the interventions individualized for this client? are the interventions safe, holistic, education based, supporting, and comforting? Have I encouraged client active participation?
Communicate/Document nursing actions
Record TNI and client response, document immediately but never in advance, what will I need to communicate in my nurse’s note? in report? to the physician?
Define Evaluation
Deliberate, systematic process in which a judgement is made about the quality, value, or worth of something by comparing it to previously identified criteria or standards
Evaluation in the nursing process
A planned, ongoing, deliverate activity in which the client, family, nurse, and other health care professionals determine the client’s progress toward outcome achievement and the effectiveness of the nursing plan of care
How does evaluation relate to the other phases of the nursing process?
uses predetermined criteria (OUTCOMES) from the planning step, assessment data must be accurate and complete so the the correct diagnoses are chosen and that the criteria written in the outcomes phase are appropriate for the client, the TNIs must be stated in concrete, behavioral, and measurable terms if they are to be useful for evaluating, evaluation does not end the process
What are the two steps in the evaluation phase of the nursing process?
evaluate outcome attainment and modify care plan prn
Evaluate outcome attainment
collect data related to desired outcomes, compare data with the outcomes, relate nursing activities to outcomes, draw conclusions about problem status
How do we know when to evaluate the outcome?
When the established timeframe has occurred or when there is a change in the client’s condition.
What does the evaluative statement consist of?
Date, conclusion of judgement about whether the outcome was achieved, data to support this judgement, your signature, your title
Modifying care plan
extend timeframe, develop new outcomes, develop new TNIs, continue, choose new nursing diagnoses
How do you report/record the effectiveness of care given?
change in client status, during shift to shift report; on flow sheets, nursing progress notes, nursing care plans, transfer documentation, interdisciplinary rounds/meeting where client needs are discussed
What are the body sites used for intradermal injections?
inner lower arm, the upper chest, and the back beneath the scapulae
Intradermal
under the epidermis, into the dermis
What are the reasons for intradermal injections?
Allergy testing and tuberculosis screening
Which arm is commonly used for TB screening?
left arm
What is the maximum amount of solution that can be administered into one site on an adult (intadermal)?
0.5 mL
What is the needle gauge for intradermal injections?
25-30
What is the needle length for intradermal injections?
1/4-5/8in
What is the needle length of a Z-Track injection?
1-1 1/2 inches
What is the needle gauge of a Z-Track injection?
21-23
How long should you aspirate for a Z-Track injection?
5-10 seconds
What should you NEVER do after you perform a Z-Track injection?
Massage
When should you release the skin/muscle that was pulled taut for the Z-Track injection?
after you have injected the medication and removed the needle at the same angle of insertion
What is the main concern with administration of oxygen?
Oxygen can facilitate combustion when fire (or spark) is present.
What should an RN teach clients when oxygen treatments are being used?
the importance of smoking away from the oxygen equipment, place no smoking signs on client’s door, teach client about fire hazard and oxygen, make sure that electric devices (hearing aids, radios, televisions, heating pads, razors) are in good working condition, avoid materials that may generate static electricity (no wool, use cotton), avoid use of alcohol, oils, greases, acetone, and ether, know the location of fire extinguishers
Nasal Cannula (nasal prongs)
The most common and inexpensive device used to administer oxygen. It goes into the nose and rests on ears. Delivers a relatively low concentration of oxygen of 24-45% at flow rates of 2-6L/minute
Non Rebreather Mask
Delivers the highest oxygen concentration possible - 95-100% at flow rates of 10-15 L/minute. One way valves on the mask and between the reservoir bag and the mask prevent the room and exhaled air from entering the bag
Venturi Mask
Delivers oxygen concentrations from 24-40% or 50% at flow rates of 4-10 L/minute. Has colored tubing.
Partial Rebreather MAsk
Delivers oxygen concentrations of 40-60% at flow rates of 6-10L/min. Oxygen reservoir bag attached.
Simple Face Mask or Standard Face Mask
Delivers oxygen at concentrations from 40-60% at flow rates of 5-8L/min, respectively.
Sunction
Aspirating secretions through a catheter connected to a suction machine or a wall suction outlet.
Oropharyngeal Suctioning
Removes secretions from the upper respiratory tract.
Yankauer Device
An oral suction device used to suction the oral cavity
Sputum
The mucous secretion from the lungs, bronchi, and trachea
What is the first thing you need to do when you implement?
Reassess the patient
What are the guideline for developing a nursing care plan?
all caregivers work towards common goal and same outcomes with approaches that have been shown to be effective for this client, nursing actions should address the nursing diagnosis and produce desired outcomes, should be on-going beginning with the first contact and updated based on client’s responses, condition and evaluation of goal achievement, the completed care plan: - describes routine care to meet basic needs - addresses nursing diagnosis and collaborative problems - Specific nursing responsibilities in carrying out the plan of care - must include the client if the plan is to be effective - incorporates client values, beliefs, and preferences - encourages active participation from client/caregivers/family (all)`
Why are nursing care plans important?
learning activity that promotes critical thinking, processing nursing knowledge and is the plan of care to be provided
What is the primary source of data for the evaluation phase of the nursing process?
client
Where does sputum come from?
Lungs, bronchi, trachea
When do you collect a sputum specimen?
In the morning or during postural drainage.
Expectorate
Cough up
Steps in obtaining sputum culture
Oral care, breathe deeply, expectorate 1-2 tsp sputum into specimen container, mouthwash, label, transport specimen or refrigerate, document
Hemoptysis
Blood in sputum
What should be documented c a sputum specimen?
Amount, color, consistency, hemoptysis, odor, measures needed to obtain specimen, patient response/discomfort
If a client could not cough, how would you obtain a sputum specimen?
Pharyngeal suctioning
What are important considerations when obtaining a sputum specimen?
Gloves, PPE, special precautions for acid-fast bacillus (TB), do not let sputum touch outside of container
When should a sputum specimen be sent to the lab after collection?
Stat
Where is a throat culture sample collected from?
Mucosa of the oropharynx and tonsillar regions using a culture swab
Who should perform a throat culture?
the nurse or physician
What are the steps in performing a throat culture?
clean gloves, insert a swab into the oropharynx and then run the swab along the tonsils and areas on the pharynx that are reddened or contain exudate
How should a patient be positioned for a throat culture?
sitting upright
How can you decrease or avoid the gag reflex in a patient when performing a throat culture?
sit upright, open mouth, extend tongue and say “ah,” take specimen quickly
What is the rationale behind having a client sit upright, open mouth, extend tongue and say “ah” during a throat culture?
The sitting position and extension of the tongue exposes the pharynx. Saying “ah” relaxes the throat muscles and helps minimize contraction of the constrictor muscle of the pharynx
What is the term for an inadequate amount of oxygen that leads to cell death?
hypoxia
Who is oxygen prescribed by?
primary care physician orders
When is a time when a nurse can administer oxygen therapy before contacting the PCP?
In an emergency, a nurse may initiate 1st and call PCP after for an order
What are the reasons that someone would require oxygen therapy?
hypoxemia, hyperventilation, substantial loss of lung tissue, severe anemia, blood loss, condition there is inadequate numbers of RBCs or hemoglobin to carry oxygen
Hypoxemia
abnormally low concentration of oxygen in the blood
Hypoxia
inadequate amount of oxygen in the tissues
Hyperventilation
an increase in depth and rate of breathing great than demanded by the body needs
What is the problem with too much oxygen therapy?
pulmonary oxygen toxicity, absorption atelectasis, or hypercapnia
Hypercapnia/Hypercarbia
abnormally high levels of carbon dioxide in the blood
When can oxygen toxicity develop?
From breathing 60% oxygen for 24 hours
What does oxygen do to the mucous membranes?
oxygen drys mucous membranes out
What are the two ways oxygen is contained for oxygen therapy?
cylinders/tanks or wall outlets
What administration devices are used to deliver low-flow oxygen therapy?
nasal cannulas, face masks, oxygen tents, and transtracheal catheters
What administration devices are used to deliver high-flow oxygen therapy?
Venturi Mask with large-bore tubing
What type of oxygen delivery system is this woman using?
nasal cannula (nasal prongs)
What are limitations to the nasal cannula?
It can be drying and irritatiing to the mucous membranes and it does not have the ability to deliver higher concentrations of oxygen
What type of oxygen delivery system is this woman using?
A simple fask mask
What are the differences between the patiral rebreather mask and the non-rebreather mask?
There are one way valves on the NRM that prevent the room air and the client’s exhaled air from entering the bag so only the oxygen in the bag is inspired. NRM delivers 95-100% concentration at liter flows of 10-15L/minute and the PRM delivers oxygen concentrations of 40-60% at 6-10L/minute.
What type of oxygen delivery system is this woman using?
venturi mask
What are the purposes of the nasal cannula?
to deliver a relatively low concentration of oxygen when only minimal O2 support is required, to allow uninterrupted delivery of oxygen while the client ingests food or fluids
What are the purposes of a face mask?
to provide mod. O2 support and higher concentration of oxygen and/or humidity than is provided by cannula
What position is ideal for oxygen therapy?
semi-fowler’s position as the position permts easier chest expansion and therefore easier breathing
What should be checked frequently during oxygen therapy VIA a face mask?
Skin. Look for dampness of chafing and dry and treat prn
What are the purposes of oropharynxgeal suctioning?
to remove secretions that obstruct the airway, to facilitate ventilation, to obtain secretions for diagnositc purposes, to prevent infection that ma result from accumulated secretions
What are the signs that oropharynxgeal suctioning may be required?
restlessness. anxiety. noisy respirations. adventitious breath sounds when the client’s chest is auscultated.
What should the care provider do before suctioning with Yankauer catheter?
Moisten to tip of the Yankauer with sterile water or saline to reduce fristion and ease insertion
What is the purpose of administering an intradermal injection?
To provide a medication that the client requires for allergy testing and TB screening
What would you assess for before giving an intradermal injection?
appearance of injection site, specific drug action and expected response, client’s knowledge of drug action and response, agency protocol about sites to use for skin tests
Which hand and side of hand should you use for a Z-Track IM injection?
ulnar side of the non-dominant hand
What are the IM injection sites?
deltoid, dorsal gluteal, vastas lateralis, ventral gluteal
RD
right deltoid
RDG
right dorsal gluteal
RVL
right vastas lateralis
RVG
right ventral gluteal
LD
left deltoid
LDG
left dorsal gluteal
LVL
left vastus lateralis
LVG
left ventral gluteal
What angle should a intradermal injection be administered?
5-15 degrees
Z-Track IM injections should only be administered where?
upper outer quadrant of buttox
How far should you pull the skin to the side for a Z-Track IM injection?
1 inch
Why do we put an air lock on IM injections?
To makes sure that all of the medication in the needle goes into the syringe before the needle is changed to the needle you will inject the patient with. The air will also be the last to leave the syringe, therefore making an air barrier so that the medication is better absorped.
How much of an air lock for Z-Track IM injections?
0.2-0.3 mL of air aspirated after drawing up correct dose and before changing needles
