Nursing 101 Exam 1B – Flashcards
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long term: a week, month, or more short term: hours, days
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What's the difference between long term and short term goals?
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used to treat chronic pain that is neuropathic in nature Ex: fentanyl
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What are the pharmacological measures for pain including adjuvant analgesics?
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use 2-3 fingers apical: 5th intercostal space mid-clavicular line; always ct for 60 sec peripheral: 30 sec x 2
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What is the method of finding a peripheral pulse & an apical pulse?
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transduction transmission perception modulation
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What are the physiological changes of pain?
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offense again society under jurisdiction of state & federal courts misdemeanor/felony lead to fine, imprisonment, death
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What are some basic principles of criminal law controlling nursing practice?
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cutaneous/superficial visceral deep somatic radiating referred phantom psychogenic
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Classify pain according to origin...
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to help the nurse provide individualized goal-directed client centered care
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What is the importance of a written care plan?
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communication education legal documentation quality assurance reimbursement research
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What is the purpose of documentation?
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What the patient says or family
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What is subjective data?
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NSAIDS mild to moderate pain tylenol, advil, aspirin
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What are the pharmacological measures for pain including non-opioid analgesics?
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60-100 bpm avg. 70-80 bpm
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What is the normal pulse rate for healthy adults?
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focus on disease, illness, and injury
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What is a medical diagnosis?
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statement of client health status that nurses identify, prevent, or treat
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What is a nursing diagnosis?
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stage 1: pre-interaction (no communication) stage 2: orientation phase (client & nurse meet) stage 3: working phase (nurse & client work together to meet clients needs) stage 4: termination phase (conclusion of relationship)
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Describe the role of communication in each of the 4 phases of therapeutic relationship...
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cues: what the patient says & what you observe inference: judgement
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What is the difference between a cue and an inference?
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Assessment (gathering data) Diagnosis (identify patient health needs) Planning -outcome (patient focused goals) -intervention (nurse focused goals) Implementation (carry out planned actions) Evaluation (were interventions effective?)
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What are the 6 steps int the nursing process?
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assess for pain
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What is the nursing process in the care of patient with pain?
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when there is a clearly identified cause for the rise in BP
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Define: secondary hypertension
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relate outcomes to interventions draw conclusions about problem status
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Describe the process for evaluating the effectiveness of a nursing care plan...
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Encoder Message Channel Decoder Feedback
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What are the 5 components of the communication process?
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subjective & objective data do not agree or make sense clients statements differ at different times in the interview data is far outside the normal range
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What are the 3 circumstances where you would validate data?
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body language facial expressions posture gait personal appearance gestures touch
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What are some nonverbal communication characteristics?
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actual risk possible syndrome wellness
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What are the 5 types of nursing diagnoses?
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date subject action verb time & limits signature
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What must be on your nursing order?
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abnormal body temp of 100.4 caused by pyrogens
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What is the physiological mechanisms of a fever?
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identify the topic that fits your assessment data best
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How do you know which of the NANDA labels to use to describe a patients problems?
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include both problem & etiology be descriptive & specific state the problem as a patient response use non-judgemental language avoid legally questionable language
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State at least 5 criteria for judging the quality of a diagnostic statement.
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the problem suggests the outcome/goal the etiology suggests interventions
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What is the relationship between nursing diagnosis and outcomes/interventions
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theories-how you define a problem research-looking at studies
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How do theories and research influence the choice of nursing interventions?
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Narrative (story) SOAP, SOAPIE, SOAPIER (subjective, objective, assessment, plan, intervention, evaluation, revision) PIE (problem, intervention, evaluation) Focus (Data, Action, Response/Evaluation) Charting by exception (streamlined)
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What are the different types of documentation?
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failure to: assess & diagnose plan implement plan of care evaluate
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What are the major legal issues that arise within the nursing practice?
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nociceptive (muscle/joints/organs...aching) neuropathic (burning, numbness, itching)
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Classify pain according to cause:
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diagnosis: helps identify patients problems outcomes & interventions: help form realistic goals & most accepted implementation: continue to gather assessment data by observing patient as you implement interventions evaluation: look at if goals have been met
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What is the relationship to assessment to the other steps in the nursing diagnosis?
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treat moderate to severe pain Ex: oxycodone
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What are the pharmacological measures for pain including opioid analgesics?
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diagnosed when there is no known cause for the increase in BP
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Define: essential hypertension
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second hand ex: medical record
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What is secondary data?
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when a patient is breathless or pulseless
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What is code blue?
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relaxation/imagery meditation distraction/laughter heat/cold massage TENS acupressure/acupuncture
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What are some non-pharmacological pain relief measures?
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acute: brief chronic: longer than 6 months intractable: chronic & highly resistant to relief
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Classify pain according to duration:
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amount of oxygen in your blood
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Define: arterial oxygen saturation
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endotrachial tube that is pliable put through the nose/mouth and into the trachea
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What are the basic elements of airway management including placement of oral and nasal airways?
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98
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What is the normal oral temperature for an adult?
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rapid and deep breathing resulting in excess loss of CO2
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Define: hyperventilation
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apply BP cuff find radial pulse inflate cuff till you can't hear the radial pulse, add 30 to that number release cuff and re-inflate cuff to your number with the diaphragm of the stethoscope on the brachial artery Slowly release listening for the first and last sounds, which will be you reading
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Describe the process for taking a brachial blood pressure reading.
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rapport & trust are established all phases of therapeutic relationship are effected effectiveness determines quality of nurse-client relationship
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How do relationships and roles influence communication?
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hypothalamus controls body temperatures
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What is thermoregulation in the body?
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progress of the client, change of status, any tests done or will get, therapies received, teaching given
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What are the key elements to include when giving an oral report about a client?
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completeness clarity and comprehension voluntariness competence
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What are the basic elements of informed consent?
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systolic of > 140 mm Hg diastolic of > 90 mm Hg on 2 or more occasions
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Define: hypertension
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clients progress at time of discharge
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What is terminal evaluation?
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environment gender/age developmental level personal space roles and responsibilities
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What are some factors that influence the communication process?
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Bill of Rights Emergency Medical Treatment & Active Labor Act Health Care Quality Improvement Act American Disabilities Act Patient Self Determination Act Newborns & Mothers Health Protection Act National Labor Relations Act HIPAA
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What are the 8 federal laws regulating the nursing practice?
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determines what activities are required goals met/goals partially met/goals not met
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How are nursing interventions determined by problem status?
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should be 2/3 of patients upper arm or 40% too big of cuff = low measurement reading too little of cuff = high measurement reading
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What is the importance of a cuff size when obtaining blood pressure reading?
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RN evaluates progress towards outcomes documents results of evaluation uses ongoing assessment data to revise diagnosis
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How are standards and criteria used in evaluation?
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emotions developmental stage sociocultural factors communication impairments cognitive impairments vital signs
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What are some factors that influence pain?
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sharp/dull throbbing stabbing burning ripping searing tingling
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Classify pain according to quality:
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for nurses to apply knowledge to provide holistic care: theoretical practical ethical personal
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How is critical thinking used in the nursing process?
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systolic <100 mm Hg
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Define: hypotension
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at specified times
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What is intermittent evaluation?
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process of sending and receiving messages
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What is the definition of communication?
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inadequate cellular oxygenation
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Define: hypoxia
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unpleasant sensory/emotional experience
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Define: pain
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apnea: cessation of breathing bradypnea: slow 1-12 tachypnea: fast > 20 dyspnea: labored breathing
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What are the abnormal findings for respiratory rate?
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always a potential problem, if it becomes "actual" now it is a medical diagnosis
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What are collaborative problems?
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exchange of oxygen & carbon dioxide in the body
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How are respiration's regulated in the body?
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observe mandatory standards of care use nursing process & follow professional standards avoid medication and treatment errors report & document accurately obtain informed consent maintain confidentiality
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What are some things to do to decrease the likelihood of committing nursing malpractice?
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its the opposite of the diagnosis based on desired result of care
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How is an outcome derived from a nursing diagnosis?
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"Client Will"
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What does an outcome statement start with?
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Think critically about: task circumstance person direction/communication supervision & evaluation
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What are the "5 rights" of delegation?
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spoken/written words vocab & language meaning pace tone of voice clarity timing relevance
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What are some verbal communication characteristics?
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intra-personal inter-personal group
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What are the 3 basic levels of communication?
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because you can't observe the link between etiology & problem
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Why is etiology always an inference?
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to create a baseline check for accuracy
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Why is it important to take vital sign patterns rather than relying on one reading?
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protects rights of individuals plaintiff/defendant Contract law Tort Law
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What are some basic principles of civil laws controlling nursing practice?
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contact who wrote the order if they don't change the order, you may refuse to do it inform the charge nurse
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How do you question a medical order?
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review outcomes collect reassessment data determine progress towards goals record evaluative statement evaluate collaborative problems
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Describe the process for evaluating client health status (outcomes)?
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rate & depth of respiration's are decreased & CO2 is retained
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Define: hypoventilation
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pressure of blood as its forced against arterial wall during cardiac contraction pulse pressure: difference between systolic and diastolic
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Describe the physiology of blood pressure
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what nurse observes
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What is objective data?
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admissions database discharge summary flowsheet & graphic record medication administration record kardex integrated plan of care event report
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What are the 7 different charting forms and their purposes?
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obtained from the client your own assessment
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What is primary data?
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Mandatory Reporting Law Good Samaritan Law Nurse Practices Act
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What are the state laws regulating the nursing process?
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pain management is essential to quality patient care
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Why should pain be considered a 5th vital sign?
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12-20 /min
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What is normal respiratory rate for adults?
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bradycardia: 100bpm
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What are the abnormal findings for pulse rate?
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enhance: active listening, establish trust, be assertive, restate, clarify, validate hinder: asking too many questions, asking why, changing the subject inappropriately, failing to listen
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What are some techniques that enhance and hinder communication?
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responds when someone is in respiratory distress
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What is the rapid response team?
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immediately after intervention at each patient contact while implementing
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What is ongoing evaluation?
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Specific Measurable Attainable Realistic Timely
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What does SMART stand for?
