Foundations Test 2
Terms
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copy deck
- 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?
- yes
- 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?
- 5
- 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?
- assessment
- 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?
- assessment
- 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?
- assessment
- 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?
- assessment
- 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?
- NO
- 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?
- 2
- 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?
- dx
- 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?
- NO
- 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?
- one
- Which nsg dx is listed first?
- one w/ highest priority
- What is the 3rd step of the nsg process?
- planning
- 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?
- planning
- 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?
- 6
- 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?
- implementation
- 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?
- MANY THINGS
- 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?
- evaluation
- How many steps are there to objective eval?
- 5
- 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?
- yes
- 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?
- R. BD
- 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?
- prescriber
- 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?
- YES
- What is a half life
- amt of time 1/2 med gets out of body
- Should you be sensitive to cts schedule?
- YES
- 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?
- NO
- Do we teach about meds when we give them?
- YES
- 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
- oral
- 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?
- aspiration
- What type of effects can topical meds cause?
- systemic and local effects
- What do you always use when applying topical meds?
- gloves
- 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?
- tissue
- 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?
- universal
- what do you always wear when giving vaginal and rectal meds
- gloves
- What must you always do before administering vag or rec meds?
- explain procedure
- Can pt do vaginal or rectal meds themselves
- yes
- 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?
- both
- 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?
- alcohol
- Do you make sure you tell pt before you stick them?
- yes
- 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?
- abdomen
- How do you give SQ shot
- pinch skin, 45-90 degrees
- What injection is faster than SQ but slower than IV
- IM
- 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
- deltoid
- 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?
- demo
- How do you give a vastus lateralis IM shot?
- DEMO
- How do you give a deltoid IM shot?
- DEMO
- How do you give a dorsal gluteal IM shot
- DEOM
- What do you always do when giving IM meds
- z-track
- 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?
- YES
- 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?
- DR
- Name a isotonic solution?
- D5W, NS
- 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