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Foundations Test 2


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What is the nursing process?
process for writing and taking care of patients
What is critical thinking
active, organized, cognitive process
What does critical thinking examine?
thinking of others
What does critical thinking require?
good cognitive skills
What is reflection?
looking back on similar experience
What does reflection do in our case?
connects classroom with clinical
How do you stay well-informed?
read the paper, websites, magazines
How must you think to critical think properly?
clearly, precisely, accurately
What reflects clear thinking?
precise, clear language
Are thinking and language closely related?
What is intuition?
sensing that something is happening
What should you always be conscious of?
what you know and dont know
What is decision making?
choosing an option
What diagnostic reasoning?
assessing client
What method of research does nursing use?
scientific method
What is the first step of clinical decision making?
assess the problem
What is the 2nd step of clinical decision making?
identify priority
What is the 3rd step of clinical decision making?
choose nursing therapy
What is the 4th step of clinical decision making?
decide how to combine activities on more than 1 pt.
What is the 5th step of clinical decision making?
delegate if able
What is learning?
a lifelong process
What two things are inseperable?
learning and thinking
What does learning require you to do?
be flexible, open to new information
What are the parts of critical thinking?
knowledge base, experience, attitudes, confidence, responsibitity, risk taking, disciipline, perseverance, creativity, curiosity, integrity, and humility
What does ADPIE stand for?
Assessment, Diagnosis, Plan, Implementation, Evaluation
What does the nursing process provide for?
continuous, ongoing care of clients
What does the nursing process enable the nurse to do?
identify cts health care needs, determine priorities, est. goals and exp. outcomes, deliver nurs. intervent. eval eff. of care
What does the nursing process integrate?
elements of critical care
What is the nursing process used for?
identify, dx, and treat human response to health and illness
How many steps are there in the nursing process?
How do you establish a data base?
collect data
What are the two types of data?
subjective and objective
In which step of the nursing process do you collect data?
What is subj data?
information gathered from client statements
What does subj data include?
client feelings and perceptions
Is subj data verifiable by someone else
no, except by inference
What is obj data?
information that can be observed by others
What is obj data free of?
feelings, perceptions, prejudices
In what step of the nursing process do you do an interview?
What is an interview?
organized conversation with client to obtain health hx and info about current illness
What does the interview give you an oppertunity to do?
intro. yourself and exp. role; est. therapeutic relationship; gain insight about client concerns and worries, determine client goals and expectatison, obtain cues regard. where you need more info
What does the nursing health hx include?
biographical information, RSC, HPI, health hx, fam hx, environmental hx, psychosocial and cultural hx, ROS
In which step do you pay attention to interviewing techniques?
What type of attitude should you have when doing an interview?
nonjudgmental, interesting and caring
What should you pay attention to when interviewing?
environment, client comfort, and comm tech.
What type of questions should you use?
open ended
What type of questions should you avoid?
why and CEQ
When performing the phys. exam what do you examine?
vital signs, obj measurements and all body systems
What do you observe for in the physcial exam?
any abnormalitites that may yield info about past, present and future health problems
What four assessment tech should you use?
inspection, auscultation, palpation and percussion
What should you always remember to do when giving an exam?
explain each step to client
What should you always protect when doing the phys exam?
client privacy, dignity and warmth
In what step do you observe for client behavior?
Should subj and obj data agree? What if they dont
Yes - further data collection
What is congruency?
matching or agreement between two or more things
What is consistency?
refers to degree client operates at same level of function throughout assessment and day to day
What is the obs. of client funct.
What you see client doing not what they say they can do
What are some other sources of data for the hx?
family, friends, sig. others, health care team, lit. review (chart)
What does validation of assessment data involve?
comparing data with another source
What happens when you validate info?
opens door for gathering more info
What is the last part of the complete assessment?
data documentation
What is the basic rule of data documentation?
record all observations
What does data documentation include?
facts only
Should you generalize or form judgements to early?
What becaomes a nursing dx in the data documentation part?
conclustions and observatison
How many steps are there in the assessment phase of the nursing process?
What is the first step of the assessment process?
collect and verify data from primary and secondary sources
What is the second step of the assessment process?
analyze data as basis for developing nsg dix and plan of care
What are the types of nursing dx?
actual, risk, wellness
What is the second step of the nursing process?
What is the nursing dx?
clinical judgment about individual, family, or community responses to actual and potential health problem or life process
What does the nursing dx reflect?
level of client health or response to disease or pathological process
What is a med. dx?
id of disease condition based on specific evaluation of physical signs, symptoms, history, diag. tests and procedures
What does NANDA stand for?
North American Nursing Diagnosis Association
What is the actual nursing dx?
human response to health conditions or life processes that exist in an individual, family or community
What is a risk nursing diagnosis?
describes human responses to health conditions or life processes that may develop
What is wellness nursing dx?
human responses to levels of wellness
What does the diagnostic process consist of?
the decision making steps used to develop and diag. statment
What is the first step of the diagnostic process
data validation and clustering dervied from assessment
What is the 2nd step of the diagnostic process?
analysis and interpretation of data, id of client needs and formulation of nsg diag.
What do you look for in data analysis?
patterns and trends
What do you compare your data wiht in data analysis?
normal healthful standards
What do you judge in data analysis?
wheter the grouped s/s are normal for this client and whether they are within range of healthful responses
What does problem id look for?
characteristics not within healthy norms
What are defining characteristics?
clinical criteria that support presence of diag. category
What are clinical criteria?
obj and subj s/s or risk factors
What are related factors?
etiological or contributing conditions that have influenced client response
What must the etiology of a nsg dx be?
within domain or nsg practice and a condition that responds to nsg interventions
Can nursing interventions chg a med dx?
What can nsg interventions be directed at?
behavior or conditions that you can treat or manage
What dimensions is the nsg dx derived from?
physiological, psychological, sociocultural, developmental, spiritual
What are some sources of diagnostic errors?
data collection, data clustering, interpretation and statement of nsg diag.
What type of judgments should you make in the Nsg dx?
professional not prejudicial
What type of statements should you avoid in the nsg dx?
legally inadvisable
When you identify the problem and etiology what should you avoid?
circular statement
How many client problems should you identify in the client statement?
Which nsg dx is listed first?
one w/ highest priority
What is the 3rd step of the nsg process?
What is planning?
category of nsg behavior in which client centered goals est. and interventions designed to achieve goals
What do high priorities result in?
harm to client of others
What are intermediate priorities.
non-emergent, non life threatening needs
What are low priorities?
may no be directly related to specific illness or prognosis but may affect clients future well being.
What are the 2 purposes of planning?
provide direction for selection and use of nsg interventions, provide focus for evaluation of the effectiveness of interventions
What is a client centered goal?
specific and measurable behavior or response that reflects the clients highest possible level of wellness and independence in function
Should client centered goals only be set by the nurse?
No - should be set mutually
What are the two types of goals?
short and long term
What is a short term goal?
objective behavior or response that is expected to be achieved in a short time, usually less than a weekk
How long should it take to accomp. a short term goal?
less than a week
What is a long term goal?
objective behavior or response expected to be achieved over a longer period
how long should it take to accomp a long term goal?
weeks or months
What does goal setting est?
framework for nsg care plan
What part of the nsg process identifys and coordinates resources to deliver nsg care?
What do written nsg care plans do?
organize info exchanged in change of shift nurses
what are the seven factors considered when writing goal and expected outcomes?
client-centered, singular, observable, measurable, time-limited, mutual, and realistic
What is the time frame for a goal?
The period of time in which the goal should be met
How many factors do you consider when selecting a care plan?
What are the 6 factors you consider when selecting a care plan?
char. of nsg dx, expected outcomes and goals, nursing knowledge, feasibility of the intervention, acceptability of client, competency of nurse providing care
What does a nursing care plan include?
diagnostic statement, goals, expected outcomes, specific nsg activities and interventions
What does the nursing care plan decrease?
risk of incomplete, incorrect, inaccurate care
What are expected outcomes?
specific, step by step objectives
what do expected outcomes lead to?
attainment of goal
What is the 4th step of the nsg process?
What is implementation?
initiation of nsg behavior in which actions necessary for achieving goal and expected outcomes of nsg care initiated and completed
What does implementatin include?
What are the types of nsg interventions?
nurse initiated, phys initiated, collaborative init, protocols, standing orders
What is a protocol?
written plan specifying procedures to be followed
What is a standing order?
document containing orders for specific clients with identified clinical problems
What skills are needed for implementation?
cognitive, interpersonal, psychomotor
Why do you initiate direct care interventions?
to compensate for adverse reactions to therapy
what should you always do when providing care?
use precautionary and preventitive measures
What are clinical pathways?
allow staff from all disciplines to participate in plan of care
what is a consultation?
process in which a specialists help is sought to identify ways to handle problems
Why do we need cognitive skills in implementation?
to have a nsg knowledge base, and identify client needs
What do we need interpersonal skills in implementation?
to develop trust to help communicate with pt
What do we need psychomotor skills in implementation?
incorp. cognitive and interpersonal skills helps to do procedures
What is the 5th step of the nsg process?
How many steps are there to objective eval?
What are the 5 steps to obj eval.
examine the goal statement, assess ct. for behavior or response, compare est. outcome criteria, judge the degree of beh. or resp., analyze why beh. or resp not achieved
What does evaluation measure?
client response to nsg actions and ct progress twoard achieving goals
How often do you collect data to measure changes in fuctioning, daily living, or in avalability to use resources?
ongoing basis
When does evaluation occur?
each time you have contact with ct
What is the emphasis in evaluation?
client outcomes
What are positive evaluations/
when desired results are met then the plan met goal
What are neg. evaluations
undesired results indicatre interventions no effect - need to chg plan
What are the outcomes of evaluation?
care plan revision and critical thinking, discontinue care plan, modifying a care plan
What are the steps in modifying a care plan?
reassessment, nsg dx, goals and expected outcomes, interventions
Do you have a goal or outcome for each nsg dx?
Which goals have time frames?
every goal does
When is a goal met?
when ct's resp. matches or exceeds outcome criteria, considered resolved, d/c in care plan
When is a goal partially met?
behavior shows changes but does not meet criteria
When is a goal not met?
no progress
What do you do when you do not meet a goal?
modify care plan, identify variables that interfered with goal achievement, reassess and review
What is the def of evaluation?
continuous systematic method for analyzing results of nsg care
What are the 5 rights of meds?
R. med, R. dose, R. clint, R. route, R. Time
What is the 6th right at VC?
When do you check to make sure it is the rt med?
before remove from drawer, b4 remove from container, ck b4 throw away packet, ck at bedside
What is a unit dose?
single dose package
What does a unit dose do?
minimize med errors
When does risk of error increase with meds?
when in bottle, calculations,
To check right client what do you do?
check MAR, check MAR against ID badge, ask ct to identify self, check BD
Who writes the route of the med?
What do you make sure when giving paraenternal meds?
make SURE med is labeled for parenternal use
Do you need to know why medications are ordered at specific times?
What is a half life
amt of time 1/2 med gets out of body
Should you be sensitive to cts schedule?
In regards to meds what does the pt have the right to do?
r. to question, refuse, and understand med
When a pt refuses a med what do you do?
call phys (sometimes) mark MAR, find out why
Do we hurry when giving meds?
Do we teach about meds when we give them?
Who needs to understand what the medication is for?
nurse, family and pt
What is a generic med?
normal drug, off brand
When do you record a med?
after you give!
what is polypharmacy
on lots of meds
What is an example of self-prescribing of meds?
saving left overs
What are the difficulties with meds?
polypharm, self prescribe, misuse, noncomplience
What is the easies and best way to give meds
How much fluid should you follow an oral med with?
60 - 100 ml of fluid
What do you watch for when admin an oral med?
What type of effects can topical meds cause?
systemic and local effects
What do you always use when applying topical meds?
What do you do to prepare for giving topical meds
clean skin - no hair
Where do you spread paste?
over entire surface
Where do you not touch dropper on nasal or eye med?
nare or eye
When do you cleanse the area on a nasal or eye drop
if drainage noted
What does pt do after giving nasal med?
lay supine for 5 min
What do you give client after administering nasal or eye med?
When do you hold the lacramal duct
if systemic effects with eye drop
What type of precautions do you use with vaginal and rectal meds?
what do you always wear when giving vaginal and rectal meds
What must you always do before administering vag or rec meds?
explain procedure
Can pt do vaginal or rectal meds themselves
What does pt do after insertion?
lay supine
What is parenternal administration of meds
by injection
What do parenternal meds increase
risk of infection
What are the parts of the syringe?
barrel, plunger, handle of plunger, hub, shaft or plunger, needle
What do you not touch on a syringe?
tip or inside of barrel, hub, shaft of plunger, needle
are needles attached or unattached to syringe?
What are the parts of the needle?
hub, shaft, bevel,
How do you always point the needle upon insertion?
bevel up
What are ampules?
small glass vial
How do you open an ampule?
break it open
What type of needle do you use to draw up med from an ampule?
filter needle
If you have two meds, one from vial and the other from ampule, which do you draw up first?
vial, then ampule
When mixing meds what do you always do between meds
change needle
What must you know before injecting meds
the anatomical landmarks
What do you do before you inject?
map out site and cleanse area
What do you cleanse injection site with?
Do you make sure you tell pt before you stick them?
What do you do generally after you give injection?
wipe area - unless heparin
Where do you dispose of needle/syringe?
in sharps container
Where do meds go in SQ injections
loose, connective tissue - fat
Is SQ absorption lower than IV or IM?
YES, both
what must you do when giving multiple SQ inject?
rotate sites
How much can you give SQ?
no more than 1 mL
Where do you get the fastest absorption in SQ?
How do you give SQ shot
pinch skin, 45-90 degrees
What injection is faster than SQ but slower than IV
What do you risk when giving IM injection
pushing med into blood stream
what angle do you give IM shot
90 degrees
What is the greatest amt of med you give IM
4 mL in one site
What is crucial in IM shots?
landmarks and identifying sites
What are the IM sites?
Ventral Gluteal, Vastus Lateralis, deltoid, dorsal gluteal
What do you risk when giving a dorsal gluteal shot?
puncturing sciatic nerve
When IM shot is good for small amts
What IM shot is good for children and adults
vastus lateralis
What IM shot is safe for all?
ventral gluteal
What is the preferred IM injection site?
ventral gluteal
How do you give a ventrogluteal shot?
How do you give a vastus lateralis IM shot?
How do you give a deltoid IM shot?
How do you give a dorsal gluteal IM shot
What do you always do when giving IM meds
What does z-track do?
seals med in muscle
When is ID injection used?
in skin testing and TB testing
what angle do you give ID injection?
10-15 degree
What should appear on skin after ID injection
small bump
What have needleless devices done?
reduce needle stick injuries
Will we always have a need to use needles?
What do you do if stuck by contaminated needle?
bleed area, tell supervior, blood tests
What are the SQ sites?
back of arm, abdomen, top of leg, subscapular, love handles
What is the advantage of IV therapy?
rapid absorption
What are IV meds used primarily for?
fld replacement, supply electrolytes and nutrients, med admin
Who usually prescribes IV therapy?
Name a isotonic solution?
What is the electrolyte content in an isotonic solution?
310 mEq/L
What is the osmolality of isotonic solutions?
same as body fluids
What is the osmolality of a hypotonic solution?
less than body fluids
Name a hypotonic solution
1/2 NS
What is the electrolyte content in an hypotonic solution?
less than 250 mEq
What is the osmolality of a hypertonic solution?
greater than body fluids

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