240 old quizzes final exam study – Flashcards

On discharge, patient will be able to list five symptoms of infection.

to design a plan of care for and with the patient

laboratory data

"Mr. Koeppe, tell me what you do to take care of yourself."

"ineffective airway clearance related to thick mucus"

Make recommendations for revising the plan of care.

collection, validation, communication of patient data

safety of the immediate environment

Ask the instructor or a staff nurse to take the pulse.

asking the pt to preform the injection in front of you

The nurse should modify the time criteria.

to plan appropriate nursing care

Collect data about patient responses.

the response of the patient to the illness

The nursing diagnosis is based on patient response to the medical diagnosis.

"Do you take anything to help your constipation?"

sitting at a 45-degree angle to the bed

possible problem

disturbed thought processes

the patient

patient and patient needs

A nurse discusses a patient with a coworker in the elevator. A head nurse accesses the medical records of a nurse on her shift to check her condition. A nurse shares her computer password with a relative of a patient. A nurse updates the employer of a patient regarding the patient's return to work.

interpersonal skills

gather information during assessment

superego

intuitive thinking

"Patient states pain is a 9 on a scale of 1 to 10."

Demonstrate the procedure on a Teddy bear

Practice giving injections in the learning lab until you feel comfortable

Culture and lifestyle influence the communication process.

skin color

Objectively examine own beliefs, values, and practices.

moral

adjusting to physical changes

A. It is based on principles of nursing process, problem solving, and the scientific method. B. It is guided by standards, policies and procedures, ethics codes, and laws. C. It calls for strategies that make the most of human potential. E. It carefully identifies the key problems, issues, and risks involved.

patients records

"Let me check with the doctor to make sure that is okay with your other medications"

critical thinking

holding the patients hand while talking

"Don't worry, everything will be fine"

planning

The nurse

implementing

focus on acute care needs

confidentiality

non-maleficence

documenting the nursing actions in the patients records

The nurse seeks available resources to help formulate ethical decisions and use them in practice. The nurse maintains patient confidentiality within legal and regulatory parameters. The nurse delivers care in a nonjudgmental manner that is sensitive to patient diversity

nonjudgmental "value neutral" care

It brings healthcare as close as possible to where people live and work. It is essential healthcare based on sound methods and technology. It is made universally accessible to individuals and families in the community.

basic respect for human dignity

nurse-patient relationship

"Tell me more about what makes you think you don't want surgery"

Bill of Rights for Registered Nurses

alcohol or drug abuse

an ethical dilemma about inconsistent courses of action

civil law

nurse practice acts

patient and patient needs

The disease is present, but symptoms are not experienced.

LOOK UP ANSWERS (NOT educating others about health promotion activities)

hand-washing, cultural and spiritual influences promote healing

older adults

a statement of an occurrence based on observed facts

to set standards for nursing education and practice

a strong service orientation

individually defined by each person

Florence Nightengale

Clara Barton

Florence Nightengale

person

"It explains how nursing is difference from medicine"

18th to 19th century

an acute illness

Biological and Cultural Factors

A single mother of two applies for food stamps in order to feed her family

general systems theory

Lillian Wald

Body of nursing knowledge

abstract images (ideas) that are formed as impressions from the environment and organized into symbols of reality

a statement based on observed facts that explains or characterizes a process, and occurrence, or an event, but cannot be proved directly as a fact

Person Development Health Nursing

Primary- general health promotion, risk factor reduction, and other health protective measures. These strategies include health education and health promotion programs designed to foster healthier lifestyles and environmental health programs designed to improve environmental quality. Secondary-early detection and swift treatment of disease. Its purpose is to cure disease, slow its progression, or reduce its impact on individuals or communities. A common approach to secondary prevention is screening for disease Tertiary- both therapeutic and rehabilitative measures once disease is firmly established. Examples include treatment of diabetics to prevent complication of the disease and the ongoing management of chronic heart disease patients with medication, diet, exercise, and periodic examination.

Virginia Henderson- Developed patient centered care. Nurses should keep patients fully informed and put their needs first

Problem solving approach to making clinical decisions using the best evidence available Blends both science and art of nursing so that the best patient outcomes are achieved . Based on a patient as an individual not a population whole.

Step 1- Ask question about clinical area of interest or an intervention (PICO) Step 2- Collect the most relevant and best evidence Step 3-Critically appraise the evidence Step 4- Integrate the evidence with clinical expertise, patient preferences, and values in making a decision to change Step 5- Evaluate the practice decision or change PICO: P-Patient, population or problem or interest I- Intervention of interest C- Comparison of interest O-Outcome of interest

Assessment- Nurse collects comprehensive data pertinent to the patients health or situation Diagnosis- The nurse analyzes the assessment data to determine the diagnoses or issue. Protect the public by defining the legal scope of practice, excluding untrained or unlicensed people.

Nursing bylaws/ethics. Protects and educates nurses on their expected roles. Statements of ethical obligations and duties of nurses Non-negotiable ethical standards expression of nursing's own understanding of its commitment to society

Each state has its own laws that fall under this category, that protects the public by defining the legal scope of nursing practice. Each nurse is expected to care for patients within defined practice limits, failure to do so leaves the nurse vulnerable to charges. Michigans Nursing Practice Act: Michigan has an act that regulates the practice of nursing, along with 25 other health occupations. Michigan does not have a stand-alone act called the Nurse Practice Act because in Michigan, we have a consolidated practice act that covers 25 health occupations and is formally titled the Occupational Regulation Sections of the Michigan Public Health Code, PA 368 of 1978.

Each nurse is responsible for making sure that his/her educational background and clinical experience are adequate to fulfill nursing responsibilities. Safe guards: Respecting legal boundaries of practice Following institution procedures and policies Owning personal strengths and weaknesses and seeking means of growth and education Evaluating proposed assignments: refuse if unprepared Keeping current Respecting pt rights Keeping careful documentation Working within an agency to develop and support management policies

When nurses know values that motivate the decisions and behaviors of pts, they can implement the use of these when teaching and counseling patients.

Theory of Psychoanalytic Development (Freud)- Emphasizes the effect of instinctual human drives on behavior. Sexual. Libido: Pleasure seeking instincts Components: The unconscious mind- Contains memories, motives, fantasies, and fears The id- Concerned with self-gratification. The ego- Conscious mind, serves as mediator between desires of id and the constraints of reality. The superego- Conscience. Developed at one year old. Praise vs Punishment Early Childhood- Oral: uses mouth as source of gratification and exploration. Conflict in wheening Adulthood- Latency: Transition to genital stage. Increasing self-role id with parents of same sex. Later Adulthood- Genital: Sexual interest expressed in overt sexual relationships

Situation, Background, Assessment, Recommendation standardized way of communicating. It promotes patient safety because it helps individuals communicate with each other with a shared set of expectations. Used to communicate between nurses and physicians. Helps transfer caregivers have a quick overview of what to expect from patient. ex: Situation: Mrs. Smith is having increasing dyspnea and is complaining of chest pain. Background: The supporting background information is that she had a total knee replacement two days ago. About two hours ago she began complaining of chest pain. Her pulse is 120 and her blood pressure is 128/54. She is restless and short of breath. Assessment: My assessment of the situation is that she may be having a cardiac event or a pulmonary embolism. Recommendation: I recommend that you see her immediately and that we start her on 02 stat.

Taylor, C., Lillis, C., Lemone, P., & Lynn, P. (2011). "Fundamentals of nursing: the art and science of nursing care, seventh edition" (7th ed.). Philadelphia, Pa.: Lippincott Williams & Wilkins. In-text citation- (Taylor,.et al, 2011, p.40)

Content- Must be complete, accurate, concise, current and factual, order sequential Timing- Timely matter, modify if needed Format-Correct charting/form. Accountability- Sign with first initial and last name by title of each entry, if error must print "error" next to, id each pg with pt name and id number Confidentiality- HIPPA This is legal document. When charting, consider avoidance of ambiguous words such as "good, average" or "normal". Avoid generalizations "seems comfortable today" Chart specifics and details. Use quotes when using wording from pt mouth. Keep everything in order and chart in timely manner. Never have chart in the view of others ie: log off/put chart away in correct placement

Quality and Safety Education for Nurses Purpose: defined quality and safety competencies for nursing and proposed targets for the knowledge, skills, and attitudes to be developed in nursing pre-licensure programs for each competency. Provide workshops, seminars are additional resources to provide and ensure proper knowledge on Quality and Safety for Nurses

a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.

Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

ASSESSING, DIAGNOSING, PLANNING, IMPLEMENTING, EVALUATING Assessing-Collecting, organizing, validating, and documenting client data Purpose- establish a database about the client's response to health concerns or illness and the ability to manage health care needs Establish a database: Obtain a nursing health history Review client records Review nursing literature Consult support persons Consult health professionals Update data as needed Organize data Validate data Communicate/document data Diagnosing- Analyzing and synthesizing data Purpose- To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing diagnoses and collaborative problems. Interpret and analyze data: Compare data against standards Cluster or group data (generate tentative hypotheses) Identify gaps and inconsistencies Determine client's strengths, risks, and problems Formulate nursing diagnoses and collaborative problem statements Planning- Determining how to prevent, reduce, or resolve the identified client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner To develop and individualized care plan that specifies client goals/desired outcomes and related nursing interventions. Set priorities and goals/outcomes in collaboration with client Write goals/desired outcomes Select nursing strategies/interventions Consult with other health professionals Write nursing orders and nursing care plan Communicate care plan to relevant healthcare providers Implementing- Carrying out the planned nursing interventions To assist the client to meet desired goals/outcomes; promote wellness and disease; restore health; and facilitate coping with altered functioning. Reassess the client to update the database Determine need for nursing assistance Perform or delegate planned nursing interventions Communicate what nursing actions were implemented: Document care and client responses to care Give verbal reports as necessary Evaluating- Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement To determine whether to continue, modify, or terminate the plan of care. Collaborate with client and collect data related to desired outcomes Judge whether goals/outcomes have been achieved Relate nursing actions to client outcomes Make decisions about problem status Review and modify the care plan as indicated or terminate nursing care

NANDA: FOCUS ON DIAGNOSIS-- North American Nursing Diagnosis Association- Increase visibility of nursing contribution to patient care by contributing to develop, refine, and classify phenomena of concern to nurses NIC: FOCUC ON INTERVENTION-- Nursing Interventions Classification- Identify, label, validate,and classify actions nurses perform including direct and indirect care interventions. directly:interventions done with patients - ex: teaching indirectly ex: obtaining lab studies NOC:FOCUS ON CLASSIFICATION-- Nursing-sensitive Outcomes Classification- Identify, label, validate,and classify nursing-sensitive patient outcomes and indicators to evaluate the validity and usefulness of the classification and define and test measurement procedures for outcomes

Therapeutic communication shows acceptance and understanding using many verbal and non-verbal communication techniques Non-Therapeutic communication shows judgement, false reassurance, invalidation and giving advice in the "if I were you..." formatting.

The intellectual identification with or experiencing of the feelings, thoughts, or attitudes of another; A nurse must be sincere and really care about what happens to others. nurses must express our own feelings and needs without sacrificing the integrity of our position and remaining honest.