question

4 types of nursing assessments?

answer

FATE: Focus, Admission, Time-lapse, Emergency

question

aim & time frame for focus assessment?

answer

done during admission; ongoing process integrated w/ nursing care--few min to a few hrs b/tw assessments

question

aim & time frame for admission assessment?

answer

initial ID of normal function, functional status, and collection of data concerning actual or potential dysfunction; done w/in specified time frame after admission to hospital, nursing home, ambulatory care center, or home healthcare setting

question

aim & time frame for time-lapse reassessment?

answer

compare pt. current status vs. baseline obtained previously. detect changes in all fcnl health patterns after extended period of time has passed; several months (3, 6, 9 mo or more) b/tw assessments

question

aim & time frame of emergency assessment?

answer

ID of life-threatening situation; done anytime physiologic, psychological, or me crisis occurs

question

3 clinical skills used in assessment?

answer

observation, interviewing, and physical exam

question

4 techniques used in physical exam?

answer

PAPI: Palpation, Auscultation, Percussion, Inspection

question

name the 3 components of functional health assessment

answer

PAR: Pattern label, Assessment parameters for each pattern, and Recording of assessment data

question

Pattern label

answer

name given to a category of assessment data (11 cater. of fcnl health pttrns)

question

Assessment parameters

answer

specific questions to ask/info to gather based upon each fcnl health pattern

question

recording of assessment data

answer

recording (using a special form/computer) the assessment parameters and pattern labels

question

Name 5 purposes of the health assessment

answer

1) Est. a baseline 2) Determine normal function 3) Determine risk of DYSfunction 4) Determine strengths 5) To provide data for diagnosis

question

Name 2 types of data

answer

subjective and objective

question

Name 2 sources of data

answer

Primary and Secondary data

question

Primary data

answer

info from client/patient (i.e: how symptoms effect life, etc)

question

Secondary data

answer

info from other sources (i.e: family members of lab results)

question

Name 13 important subjective data to gather

answer

1) Health history 2) Pain Assessment (OLDCARTS) 3) Health perception of pt. 4) Activity/exercise (posture, gait, balance, mobility, <3 fcn) 5) Nutrition/Metabolism 6) Elimination 7) Rest/Sleep 8) Cognition/Perception 9) Self-perception/Self-concept 10) Roles/Relationships (& how rel w/ illness) 11) Coping/Stress tolerance 12) Sexuality/Reproduction 13) Values/Beliefs

question

Usual order of physical exam?

answer

Palpation, Percussion, Auscultation (unless examining abdomen--then it's Ausc, Perc, Palp)

question

Name 5 ways to validate objective data?

answer

1) compare to Normal function 2) use textbooks, journals, research 3) check Consistency for cues 4) Clarify patient's statements 5) seek Colleagues' consensus

question

name the 3 components of functional health assessment (FHP)

answer

pattern label, assessment parameters for each pattern, ; recording of assessment data

question

name the 4 phases of the patient interview (for subjective data)

answer

Preparatory, Introductory, Maintenance, and Concluding phases

question

body systems model (aka medical model; review of systems)

answer

focuses of pt. major anatomic systems. Nurse collects data about past/present condition of each organ/body system ;then thoroughly exams each body system for actual/potential problems

question

head-to-toe model

answer

nurse examine every body part from head to toe

question

name the 11 FHP (functional health patterns)

answer

1) Health perception of pt. 2) Activity/exercise (posture, gait, balance, mobility, ;3 fcn) 3) Nutrition/Metabolism 4) Elimination 5) Rest/Sleep 6) Cognition/Perception 7) Self-perception/Self-concept 8) Roles/Relationships (; how rel w/ illness) 9) Coping/Stress tolerance 10) Sexuality/Reproduction 11) Values/Beliefs

question

Functional health pattern model

answer

focuses on client's normal, altered, and risk for altered function

question

nursing diagnosis (NANDA)

answer

a clinical judgement about indiv., fam., or community RESPONSES to actual or potential health probs/life processes. Provides the basis for selection of nursing interventions to get to outcomes for which the nurse is accountable.

question

medical diagnosis

answer

describes a disease

question

diagnostic reasoning

answer

the process of gathering & clustering data to draw inferences & propose diagnoses

question

outcome identification

answer

the formulation of pt. goals & measurable outcomes that provide the basis for evaluating nursing diagnoses

question

clinical reasoning

answer

use of critical thinking to question why pt. has an abnormal finding

question

reflection

answer

those intellectual & affective activities in which indie. engage to explore their experiences in order to lead to new understandings & appreciations.

question

critical reflectivity

answer

becoming aware if our awareness & critiquing it (where highest learning occurs) (i.e. questioning judgements & considering other ways of thinking ab. situation--alternative explanations)

question

reflective skepticism

answer

a healthy attitude of doubt toward supposed truths (willingness to consider alt. explanations)

question

Defining Characteristics (in Nsg Diagnoses)

answer

observable cues/inferences that cluster as manifestations of an actual illness/wellness health state or nursing diagnosis

question

Related factors (in Nsg Diag.)

answer

describe the conditions, circumstances, or etiology that contrib. to the prob. & will aff what the msg interventions will be. (i.e.: stress incontinence related to High Intraabdominal Pressure vs. stress incontinence related to Overdistention b/tw voidings)

question

Risk factor (in Nsg diag.)

answer

envir. factors & physiological, psychological, genetic, or chem. elements that increase the vulnerability of a patient to an unhealthful event (tl:dr: a potential problem)

question

actual nursing diagnosis

answer

describes a human response to a health problem that is being manifested. written as 3 pt. statement: diagnostic label, defining characteristics, and related factors

question

risk nursing diagnosis

answer

describes a human response to health conditions/life processes, that may develop in a vulnerable patient. written as 2 pt. statement: diagnostic label, and risk factors

question

wellness nursing diagnosis

answer

describes human responses to levels of wellness in a patient that has readiness for enhancement to a higher state. written as 1 pt statement: diagnostic label

question

possible nursing diagnosis

answer

made when not enough evidence supports the prob, but the nurse thinks that it is highly probable & wants to collect more info. written as 2 pt statement: diagnostic label, and related factors (unknown)

question

outcome identification

answer

the formulation of goals & measurable outcomes that provide the basis for evaluating nursing diagnoses

question

High-priority nursing diagnoses

answer

nsg diagnoses that are potentially life-threatening & req. immediate action. (i.e: Impaired Gas Exchange, Dysreflexia, Self-Directed Risk for Violence)

question

Medium-priority nursing diagnoses

answer

nsg diagnoses that involve probe that could result in unhealthy consequences like phys/emo impairment, but aren't likely to threaten life. (i.e.: Fatigue, Stress Incontinence, Dysfunctional Grieving)

question

Low-priority nursing diagnoses

answer

nsg diagnoses that involve probe that usually can be resolved easily w/ minimal interventions ; have little potential to cause significant dysfunction. (i.e: Pain [moderate; after minor surgery])

question

[patient] outcome

answer

an educated guess, made as a broad statement, about what the pt.'s state will be after the nursing intervention is completed. Directly addresses prob. stated in nursing diagnosis

question

qualifier

answer

a description of the parameter for achieving the outcome. (i.e: "Walks" isn't specific enough--"Ambulates safely w/ 1-person assistance" clarifies the outcome statement)

question

outcome criteria

answer

specific, measurable, realistic statements of goal attainment. May restate goal, but also present info that'll guide evaluation phase of the nursing process. (answer who, what actions, under what circumstances, how well, & when.

question

Planning

answer

4th phase of nursing process: development of nsg strategies designed to improve pt. probs

question

nursing interventions

answer

any treatment, based upon clinical judgement & knowledge, that a nurse performs to enhance pt. outcomes

question

patient goal

answer

reflects resolution/correction of id'ed prob (;= 1 goal per msg diagnosis)

question

evaluation [of a nursing intervention]

answer

a written statement that determines the pt.'s progress twd specific outcome criteria

question

variances

answer

result when a deviation occurs in the [critical] pathway; & alters an expected outcome or discharge date

question

Cognitive interventions (2 types & brief den)

answer

1) Educational (nurse educated pt. & am on how to do something at home) 2) Supervisory (nurse oversees pt. overall care and makes sure CNA's are doing their job)

question

Interpersonal interventions (3 types)

answer

1) Coordinating (act as pt. advocate, make referrals, collar w/ others on hc team) 2) Supportive (use good comm'n & caring to provide comfort & promote healthy resp. to health probs) 3) Psychosocial (focus on resolving me, psych, or social probe--humor, gp therapy, role mod social skills)

question

Technical Interventions (3 types)

answer

1) Mainenance (help pt. retain certain lvl of health--hygiene, skin care) 2) Surveillance or Monitoring (detect changes from baseline data using all senses) 3) Psychomotor (insert, remov, change, app, admin, cleanse, suction, etc--anything involving a psychomotor action)

question

evaluation

answer

the judgement of the effectiveness of nursing care to meet pt. goals based on the pt.'s behavioral responses

question

standards of care

answer

authoritative statements made by nursing organizations, external review board, or hc institutions that describe the responsibilities of the nursing profession, against which its practitioners are held accountable.

question

IHI (Institute for Healthcare Improvement)

answer

Independent not-for-profitt organization that has partnered with many healthcare organizations to improve the quality and safety of care delivery while decreasing cost and inefficiency. (i.e: IHI bundles--present EBP)

question

3 Types of evaluation?

answer

Structure, Process, and Outcome evaluation

question

Structure evaluation

answer

focus on environment where care is provided (i.e.: avail. of equipment, admin supp., nrse-pt. ratios)

question

Process evaluation

answer

focus on nurse's performance (i.e.: info gathered dur. interview & phys exam; validity of nsng diag. sttmts; nurse's technical competence)

question

Outcome evaluation

answer

focus on pt. ; pt.'s function (extent to which pt. actual outcome reflects desired pt. goal & outcome criteria)

question

name the 4 possible judgments regarding outcome achievement

answer

1) Goal was completely met 2) Goal was partially met 3) Goal was completely unment 4) New problems or nursing diagnoses have developed

question

Quality Improvement programs

answer

mechanisms for healthcare organizations to assess and improve care. ensure quality pt. care provided & standards upheld

question

Who established the Standards of Nursing Practice?

answer

ANA

question

The Joint Commission

answer

external review board that establishes standards for institutions to make sure they function w/in specified guidelines

question

Define peer review

answer

The evaluation and judgment of a nurse's perforfmance by other nurses.

question

ID the 2 types of peer review

answer

1) Nursing Monitor 2) Individual peer review

question

Nursing monitor (aka nursing audit)

answer

any review completed by a nurse, of a pt.'s care or records to evaluate whether established standards were met. (Members of monitoring committee may review nurse's documentation of care in health record, or determine pt.'s health status thru observation.)

question

Individual peer review

answer

Individual nurse's performance is evaluated ; judged by other nurses w/ similar edu ; experience

question

Commission on Collegiate Nursing Education

answer

fosters continued improvement in nursing edu programs. Accreditation is non-gov, peer review process. Ensures quality ; integrity of BSN and MSN (but not LPN) Uses NATIONALLY recall. std.'s to eval programs

question

ANA standards of care? (6)

answer

ADOPIE: Assessment, Diagnosis, Outcome ID, Planning, Implementation, Evaluation

question

ANA standards of professional performance?

answer

Ethics, Edu, EBP & Research, Qual of Practice, Communication, Leadership, Collab, Professional Practice Eval, Resrc Utilization, Envir health

question

Which Nsg theorist emphasized the interpersonal interaction b/tw pt. & nurse?

answer

Peplau

question

Which nsg theorist focused on helping the pt. gain independence ASAP?

answer

Henderson

question

What nsg theorist focused on providing care & assisting pt. to attain self-care?

answer

Orem

question

Nurse is gathering info about a person's culture ; beliefs r/t health; ; how these beliefs influence the person. The nurse is eval which FHP?

answer

Health Perception ; Health Management

question

Maslow's hierarchy of human needs in order (from 1-5)?

answer

Physiologic, Safety, Love, Esteem, Self-Actualization needs

question

Members in ANA vs NLN?

answer

ANA: Only RNs NLN: nurse, other HCPs, & lay ppl

question

3 phases on nurse-pt. relationship?

answer

Orientation, Working, Termination

question

Positive Regard

answer

viewing the pt. unconditionally; treating them with warmth, caring, interest, and respect uncond.

question

Which glands are involved in neuroendocrine regulation of stress?

answer

hypothalamus, pituitary, adrenal glands

question

Differentiate b/tw pulses of 0, 1+, 2+, 3+

answer

0: absent 1+: diminished, thready, easily obliterated pulse 2+: normal, not easily obliterated 3+: increased & full volume pulses

question

How soon can a nurse with Streptococcus (gp. A) Infection return to work?

answer

24 hrs after start of treatment

question

How soon can a nurse with diarrhea return to work?

answer

After being symptom free for 3 days

question

How soon can a nurse with conjunctivitis return to work?

answer

once discharge stops

question

Differentiate Korotkoff Phase I, II, III, & IV

answer

I: faint, clear tapping sounds that gradually incr in intensity (systolic BP) II: Swishy III: Crisper, more intense sounds IV: muffled blowing sounds

question

Biot's breathing pattern

answer

cyclical pattern of shallow breaths alternating w/ apnea

question

Cheyne-Stokes breathing pattern

answer

cyclical pattern of breaths characterized by periods of increase ARE ; depth alternating w/ periods of apnea

question

Bradypnea

answer

RR ; 12 (per min)

question

Kussmaul respirations

answer

increased RR (; 20) ; increased depth of respirations

question

Average resting cardiac output?

answer

5.5 L/min

question

How to get cardiac output? (math)

answer

Stroke volume x HR (i.e: SV 70 mL ; HR 72 bpm= CO 5 L/min)

question

arterial blood gas ranges for PaO2?

answer

80-100 mm Hg

question

arterial blood gas range for HCO3?

answer

22-26 mEq/L

question

arterial blood gas range for PaCO2?

answer

35-45 mm Hg

question

pH range for arterial blood gas?

answer

7.35-7.45

question

max flow rate that can be used for O2 delivery via nasal cannula?

answer

6 L/min

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