question

Subjective data

answer

Subjective data are the facts presented by the patient that show his or her perception, understanding, and interpretation of what is happening. An example of subjective data is the patient's statement, "The pain begins in my lower back and runs down my left leg." or, Things a person tells you about that you cannot observe through your senses; symptoms

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Objective data

answer

Objective data are facts that are observable and measurable by the nurse. These data are gathered by the nurse through physical assessment, interviewing, and observing, and involve the use of the senses of seeing, hearing, smelling, and touching. An example of objective data is the measurement and recording of vital signs. Objective data are also gathered through such diagnostic examinations as laboratory tests, x-ray examinations, and other diagnostic procedures.

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Nursing process

answer

Assessing: Collecting, organizing, validating and documenting client data Diagnosing: Analyzing and synthesizing data Planning: Determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner Implementing: Carrying out (or delegating) and documenting the planned nursing interventions Evaluating: Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement.

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Assessment

answer

The first step, or phase, of the nursing process is assessment. During this phase, you are collecting data (factual information) from several sources. It includes subjective and objective data. Assessing is the systematic and continuous collection, organization, validation, and documentation of data. A Assessing is a continuous process carried out during all phases of the nursing process. All phases of the nursing process depend on the accurate and complete collection of data.

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Assessment-screening-for future ER

answer

screening, problem-based/focused health assessment, comprehensive health assessment, episodic assessment

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Assessment-Four Types

answer

initial nursing assessment, problem focused assessment, emergency assessment, and time-lapsed re-assessment. Assessments vary according to their purpose, timing, time available, and client status.

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Nursing Assessment

answer

Nursing assessments focus on a client's responses to a health problem. A nursing assessment should include the client's perceived needs, health problems, related experience, health practices, values, and lifestyles. To be most useful, the data collected should be relevant to a particular health problem. Therefore, nurses should think critically about what to assess.

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Goal nursing

answer

Expected outcomes are clearly stated in terms of patient behavior or observable assessment factors. Expected outcomes are realistic, achievable, safe, and acceptable from the patient's viewpoint. Expected outcomes are written in specific, concrete terms depicting patient action.

question

expected outcome/goal

answer

specific statement of the goal the patient is expected to achieve as a result of nursing intervention. Should be realistic and attainable and should have a defined time line NOC states that outcomes among other things, should be: Concise, Not describe nurse behaviors or interventions, Describe a state, behavior, or perception that is inherently variable and can be measured and quantified. Expected outcomes are directly observable by use of at least one of the five senses.

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medical asepsis

answer

practices used to remove or destroy pathogens and to prevent their spread from one person or place to another person or place; clean technique

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medical asepsis

answer

infection-control practices common in healthcare, such as basic handwashing

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implementation/intervention

answer

The fourth step of the nursing process, the nurse initiates the interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status.

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intervention

answer

the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care

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evaluation

answer

the last phase of the nursing process in which the nurse determines if identified outcomes have been met and the overall accuracy of the assessment, diagnosis, and implementation phases is evaluated. Action following data collection simply means making a nursing judgment of what modifications in the plan of care are needed. There are essentially only three judgments that can be made: 1. 1. Resolved 2. 2. Revise 3. 3. Continue

question

evaluation

answer

The feed back and control part of the nursing process is the ____

question

Nasogastric tube insertion

answer

a. Assess patient first b. Plan i. Gather your supplies c. Prepare i. Patient should be in high fowler's position d. Introduce yourself, ask patient name's and confirm on wrist id. e. Establish method for client to indicate distress such as raising finger f. Mr. Pierson suggested having the patient suck on ice during this procedure g. Wash hands h. Provide client with privacy i. Assess the nares j. Select nostril with greater airflow k. Determine how far to insert the tube i. Mark on the tube with tape the distance from the tip off the client's nose, to the ear, and to the xyphoid process l. Lubricate the tip m. Insert the tube while the patient sucks on ice n. If resistance is met, withdraw o. Check placement by inserting air and listening with stethoscope over the stomach area p. Secure the tube by taping it over the bridge of the client's nose

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Dressing Change

answer

Dressings are materials used to protect the wound, provide humidity to the wound surface, absorb drainage, prevent bleeding, immobilize, and hide he wound from view. Dressing Changes To guide dressing selection and changes, the nurse can use the RYB color code of wounds. This system is based off the color of the wound, red, yellow, or black. The goals of wound care are to protect(cover) red, cleanse yellow, and debride black.

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Yellow Wounds

answer

Yellow Wounds are characterized by liquid to semiliquid that is often accompanied by purulent drainage or previous infection. The nurse cleanses yellow wounds to remove nonviable tissue. Methods used may include applying damp-to-damp normal saline dressings, irrigating the wound, using absorbent dressing materials and consulting with the primary care provider about the need for a topical antimicrobial to minimize bacterial growth.

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Black Wounds Debridement

answer

Debridement of nonviable tissue from a black wound must occur before the wound can be staged or heal. Debridement may be achieved in different ways: sharp, mechanical, chemical, and autolytic.

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Red wounds

answer

The Nurse protects red wounds by (a) gentle cleansing, (b) protecting periwound skin with alcohol-free barrier film;( C ) Filling dead space with hydrogel or alginate, (d) covering with an appropriate dressing such as transparent film, hydrocolloid dressing, or a clear absorbent acrylic dressing; and (e) changing the dressing as infrequently as possible.

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Patient interview - phases

answer

An interview has three major stages: the opening or introduction, the body or development, and the closing.

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dressing change

answer

Change dressing's when they are wet and soiled

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dressing change

answer

Very painful; medicate client prior to procedure

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Patient Interview--Opening

answer

The Opening: can be the most important part of the interview because what is said and done at that time sets the tone for the remainder of the interview. The purpose of the opening is to establish rapport and orient the interviewee. Establishing rapport is a process of creating goodwill and trust. It can begin with "Good morning... Mr. Jones" or self-introduction accompanied by nonverbal gestures such as shaking hands.

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Patient Interview--Opening

answer

Nurse must be careful not to overdo this stage or patient may have anxiety as to what is to follow. In orientation, nurse explains purpose and nature of interview, what info is needed, how long and what is expected from the client.

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Patient Interview--Body

answer

In the body of the interview, the client communicates what he or she thinks, feels, knows, and perceives in response to questions from the nurse. Effective development of interview demands that the nurse use communication techniques that make both parties feel comfortable and serve purpose of the interview.

question

Patient Interview--Closing

answer

The nurse terminates the interview when the needed information has been obtained. In some cases, however, a client terminates it, for ex. When deciding not to give any more information or when unable to offer more information for some other reason- fatigue for example. The closing is important for maintaining rapport and trust and for facilitating future interactions.

question

Discharge planning

answer

Discharge is the process of preparing a client to leave one level of care for another within or outside the current health care agency. Usually, discharge planning refers to the client leaving the hospital for home. However, discharges occur among many other settings. Within a facility, it can occur from one unit to another. For example, a client with a stroke may move from a medical unit to the rehab unit, or a client with trauma may move from E.R to ICU. Clients may move from hospitals to a long term care agency, from a rehab center to home, or from home to home health care setting to a hospital, and so on.

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Foley catheter insertion Step 1-4

answer

1. Prior to performing the procedure, introduce self and verify client's identity using agency protocol. Explain to the client what you are going to do, why it is necessary and how he or she can participate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy. 4. Place client in the appropriate position and drape all areas except for perineum. For female: supine w/ knees flexed, feet about 2 ft. apart, hips slightly externally rotated if possible. For male: supine, thighs slightly abducted or apart.

question

Foley catheter insertion Step 5-9

answer

5. Establish adequate lighting. Stand on right of client if right handed or vice versa. 6. If using a collecting bag and it is not contained w/in catheterization kit, open drainage package and place the end of the tubing within reach. 7. If agency permits, apply clean gloves and inject 10 to 15ml Xylocaine into urethra of male client.. Wipe the underside of penile shaft to distribute gel up to urethra. Wait 5 minutes before inserting catheter. 8. Open the catheterization kit. Place a waterproof drape on the buttocks without contaminating the center of the drape with your hands. 9. Apply sterile gloves.

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Foley catheter insertion Step 10-15

answer

10. Organize remaining supplies: -saturate cleansing balls with the antiseptic solution. - operate the lubricant package. -remove the specimen container and place it nearby with lid loosely on top. 11. Attach the prefilled syringe to the indwelling catheter inflation hub. Apply agency policy regarding pretesting of the balloon. 12. Lubricate the catheter to 2.5 to 5 cm. (1 to 2 in.) for females, (6 to 7 in.) for males, and place it with drainage end inside the collection container. 13. If desired, place the fenestrated drape over the perineum, exposing the urinary meatus. 14. Cleanse the meatus. 15. Insert the catheter - grasp the catheter firmly (2 to 3 inches) from the tip. Ask the client to take a slow deep breath and insert the catheter as the client exhales. Slight resistance is expected as the catheter passes through the sphincter.

question

Foley catheter insertion Step 16-20

answer

16. Hold the catheter with the non-dominant hand. 17. Inflate the balloon the retention balloon with the designated volume. If client feels discomfort immediately withdraw the instilled fluid and advance the catheter further. 18. Wipe any remaining antiseptic or lubricant from perineal area. 19. Discard all supplies in appropriate receptacles. 20. Remove and discard gloves. Perform hand hygiene. 21. Document the catheterization procedure including catheter size and results in the client record.

question

Gordon's functional health pattern H-C

answer

Health-perception-Health management: describes the client's perceived pattern of health and well being and how health is managed. Nutritional-metabolic: describes the client's patter of food and fluid consumption relative to metabolic need and pattern indicators of local nutrient supply. Elimination: describes the patterns of excretory function (bowel, bladder and skin). Activity: exercise pattern: describes the patter of exercise, activity, leisure and recreation. Cognitive-perceptual pattern: describes sensory-perceptual and cognitive patterns.

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Gordon's functional health pattern S-V

answer

Self perception-self concept: describes the client's self-concept pattern and perceptions of self (e.g., self conception, worth, comfort, body image, feeling state). Role-relationship pattern: describes the client's pattern of role participation and relationships. Sexuality-reproductive pattern: describes the client's patterns of satisfaction and dissatisfaction with sexuality patter; describes reproductive pattern. Coping-stress-tolerance pattern: describes the client's general coping pattern and the effectiveness of the pattern in terms of stress and tolerance. Value-belief pattern: describes the patterns of values, beliefs (including spiritual) and goals that guide the client's choices or decisions.

question

Discharge Planning 2

answer

Each agency generally has its own policies and procedures related to discharge. Many agencies have case managers or discharge planners, a health or social services professional that coordinates the transition and acts as a link between the discharging agency and the receiving agency. Often, a nurse assumes this responsibility of providing continuity of care. Discharge planning needs to begin as soon as a client is admitted to the agency, especially in hospitals where stays are relatively short.

question

Discharge Planning

answer

Effective discharge planning involves ongoing assessment to obtain comprehensive information about the clients on going needs and nursing care plans to ensure that the clients and receiving agency caregivers' needs are met. In some cases, discharge planning necessitates health team conferences and family conferences. At a health team conference, healthcare professionals focus in ways to individualize care for the client. At a family conference, both health professionals and the family discuss family issues related to the client. Both types of conferences give the client, family, and health care professionals the opportunity to mutually plan care and set goals.

question

Medical asepsis

answer

All practices intended to confine a specific microorganism to a specific area, limiting the number, growth, and spread of microorganisms. The key goal of medical asepsis is reducing risks of infection control. Planned nursing strategies to reduce the risk of transmission of organisms from one person to another include the use of meticulous asepsis. Asepsis is the freedom from infection or infectous material.

question

Surgical Asepsis

answer

or sterile technique, refers to those practices that keep an area or objects free of all microorganisms. It includes practices that destroy all microorganisms and spores(microscopic dormant structures formed by some pathogens that are very hardy and often survive common cleaning techniques).

question

QID

answer

four times a day 0900, 1300, 1700, & 2100

question

T.I.D.

answer

three times per day 0900, 1600, & 2100

question

B.I.D.

answer

two times a day 0900 & 2100

question

HS

answer

At bedtime 2100

question

PC

answer

after a meal

question

AC

answer

before meals

question

Documentation

answer

The process of making an entry on a client record is called recording, charting or Documenting. The Joint Commission requires client record documentation to be timely, complete, accurate, confidential, and specific to the client. Some important correlations with documenting- HIPAA (Privacy and confidentiality of protected health information.

question

change of shift report

answer

patient information is exchanged between a shifts in the form of oral report, a taped report, or walking a rounds. This is not a time for socialization. Be on time for report and come prepared with paper and pen to take notes.

question

Documentation Systems

answer

A number of documentation systems are in current use: the source-oriented record; the problem -oriented medical record; the problems, intervention, evaluation (PIE) model; focus charting; Charting by exception (CBE); computerized documentation; and case management.

question

Patient teaching-intervention

answer

Nursing interventions include both direct and indirect care. Patient teaching is Independent interventions, activities that nurses licensed to initiate on the basis of their knowledge and skills, They include physical care, ongoing assessment, emotional support and comfort, teaching, counseling, environmental management and making referrals to other health care professionals.

question

Nursing intervention

answer

is "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes".

question

QOD

answer

every other day

question

QD

answer

Every day

question

Aerosol treatment:

answer

deliver suspension of fine particles of liquid (medication) in a gas easy to use must be kept clean at home to prevent bacterial growth

question

student care plan

answer

Useful for leaning the problem-solving technique, the ursine process, skills of written communication, and organizational skills needed for nursing care

question

student care plan

answer

1 research 2 possible nursing dx 3 expected outcomes 4 develop interventions 5 meet and assess pt 6 eval nursing dx 7 implement interventions 8 eval care plan

question

Afterload

answer

Resistance to left ventricular ejection created by: blood vessels, hypertension, atherosclerosis, and hypervolemia., the pressure that must be exceeded before ejection of blood from the ventricles can occur Force against which the heart pumps when ejecting blood (is the pressure or resistance against flow)

question

Adventitious breath sounds

answer

abnormal auscultated breath sounds like wheezing and rhonchi

question

Anti-embolic stocking

answer

Specially fitted elastic stockings used to compress lower extremities, reduce blood pooling, and promote venous return, thus reducing risk of thrombus formation. Stockings must be correctly fitted and reapplied for optimal effectiveness. Pg. 100

question

Atelectasis

answer

a condition in which the lung fails to expand completely due to shallow breathing or because the air passages are blocked collapse of an expanded lung (especially in infants)

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Bradycardia

answer

slow heart rate, usually below 60 beats per minute

question

Biopsy

answer

examination of tissues or liquids from the living body to determine the existence or cause of a disease

question

Cirrhosis

answer

chronic disease characterized by degeneration of liver tissue most oftern caused by alcoholism or a nutritional deficiency (cirrho = yellow)

question

Cyanosis

answer

bluish coloration of the skin caused by a deficient amount of oxygen in the blood

question

Debridement

answer

surgical removal of foreign material and dead tissue from a wound in order to prevent infection and promote healing

question

Diagnosis related Diagnosis (DRG):

answer

A patient classification system that categorizes patientswho are medically related with respect to diagnosis and treatment and satistically similar in length of hospital stay. Clients are grouped together by diagnosis, surgical procedures, complications, preexisting conditions, age and everything done for a client must be documented in the medical record so that the health care institution can recover its costs.

question

Ecchymosis

answer

the skin, the purple or black-and-blue area resulting from a bruise the escape of blood from ruptured blood vessels into the surrounding tissue to form a purple or black-and-blue spot on

question

Incentive Spirometry

answer

common postoperative breathing therapy using a specially designed spirometer to encourage the patient to inhale and repeatedly sustain an inspiratory volume to exercise the lungs and prevent pulmonary complications

question

Ischemia

answer

local anemia in a given body part sometimes resulting from vasoconstriction or thrombosis or embolism, to hold back blood; decreased blood flow to tissue caused by constriction or occlusion of a blood vessel

question

Jaundice

answer

yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood, yellow color to skin, palate, and sclera due to excess bilirubin in the blood

question

Lithotomy

answer

a surgical incision for the removal of a stone from the bladder

question

Laparoscopic

answer

pertaining to the use of a laparoscope, an instrument used to perform abdominal surgery through small incisions.

question

Mastectomy

answer

surgical removal of a breast to remove a malignant tumor

question

Nebulizer

answer

device that creates a mist used to deliver medication for giving respiratory treatment

question

Obtunded

answer

sleeps most of time, difficult to arose, acts confused when aroused, speech mumbled and incoherent Transitional state between lethargy and stupor. Sleeps most of the time, difficult to arouse - needs loud or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation

question

Paracentesis

answer

surgical puncture to remove fluid from abdomen

question

Preload

answer

the degree of stretch on the heart before it contracts or Volume of blood that fills the heart and stretches the heart muscle fibers during its resting phase (volume of blood in ventricles at end of diastole, just prior to contraction)

question

Purulent

answer

Drainage from a wound or body part that contains pus. or, having undergone infection ex. a purulent wound

question

Saline Lock

answer

peripheral IV cannula with a distal medication port used for intermittent fluid or medication infusions. Saline is injected into the device to maintain its patency. or, may be referred to as a hep lock or peripheral lock. this is the process of creating positvie pressure in the IV catheter with saline in order to prevent occlussion at the IV site. there is no running IV

question

Sentinel Event

answer

an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

question

Shearing Force

answer

a combination of friction and pressure which when applied to the skin results in damage to the blood vessels and tissues or, Friction exerted when a person is moved or repositioned in bed by being pulled or allowed to slide down in bed.

question

Tachypnea

answer

an abnormally rapid rate of respiration, usually >20 breaths per minute or rapid breathing

question

Urosepsis

answer

condition caused by bacteria in the urine that may lead to the spread of organisms into the bloodstream or kidneys. or, UTI has crossed into the blood. Pt. Will need IV antibiotics. Pt can die from this. Most common cause is a Pt. coming form the nursing home with a foley catheter.

question

Vapotherm

answer

high-flow, thermally-controlled, humidification systems for respiratory therapy. Currently, these medical devices are indicated for use in adding warm moisture to breathing gases to infant, pediatric and adult patients in the hospital, sub-acute institutions and home settings. Vapotherm devices are cleared for delivery of breathing gases by nasal cannula at flow rates of up to 8 lpm in infants and 40 lpm in adults, providing what is known as high flow therapy (HFT)

question

Volumetric pump

answer

Pump that can be programmed to deliver measured amounts of fluids intravenously over a set time.

question

dependent intervention

answer

Those actions that require an order from a physician or another health care professional or,, prescribed by a physician or advanced practice nurse but carried out by the bedside nurse, usually orders for diagnostic test, medications, treatments, IV therapy, diet, activity

question

independent intervention

answer

Actions that a nurse initiates without direction from a physician or other health care professional. or, those that do not require supervision or direction from others Nurses have the knowledge and skill to carry out actions

question

prioritization

answer

prioritizing: in the nursing process, following speciﬁc steps to determine the client's most important needs.

question

AD

answer

Right Ear

question

AS

answer

Left Ear

question

AU

answer

Both Ears

question

ID

answer

Intradermal

question

IM

answer

Intramuscular

question

IV

answer

Intravenous

question

IVPB

answer

Intravenous Piggyback

question

NGT

answer

Nasogastric Tube

question

OD

answer

Right Eye

question

OS

answer

Left Eye

question

OU

answer

Both eyes

question

PO

answer

By mouth/per osis

question

SQ

answer

Subcutaneous

question

SL

answer

Sublingual

question

AC

answer

Before Meals 0800 1200 1700 ad Lib__As Desired

question

Nursing Process:Steps: ADPIE

answer

Assesment,Diagnosis,Planning,Intervention,Evaluation and don't forget documentation

question

ASAP

answer

as soon as possible

question

HS

answer

Hour of sleep 2100

question

NOC

answer

Nighttime

question

PC

answer

After Meals 0900 1300 1800

question

PRN

answer

As Needed

question

Q

answer

Every day

question

Q

answer

every morning

question

Q Hr

answer

Every hour

question

Nursing Diagnosis

answer

____ deals with human response to health and life problems stemming from condition (Stroke-impaired verbal communication,risk for falls)

question

QD

answer

Every Day 0900

question

NANDA

answer

North American Nursing Diagnosis Association; Defines what a nursing diagnosis is

question

BID

answer

Twice a day 0900 1700

question

Assessment

answer

Collecting,Organizing,Validating, and Documenting Data

question

QID

answer

Four times a Day 0900 1300 1700 2100

question

Nursing Process

answer

A systematic rational method of planning and providing nursing care is part of the___

question

Objective Data

answer

Information seen by nurse, measureable (signs) are part of___

question

Subjective Data

answer

___ is information stated by patient (symptoms)

question

STAT

answer

Immediately

question

SOAP

answer

Subjective,Objective,Assesment,Plan. Method of Problem-Oriented charting

question

SOAPIER

answer

Subjective,Objective,Assesment,Plan,Intervention,Evaluation,Revision. Method of problem-Oriented charting, Derived from SOAP

question

PIE

answer

Problem,Intervention,Evaluation. Method of Problem-Oriented Charting

question

Charting By Exception

answer

CBE-Charting with preprepared flowsheets, assumes normality except when an Exception is noted

question

Narrative

answer

A form of charting similar to a story of the patients day. Usually in chronological order.

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