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Fund. of Nursing
The Nursing Process/Safety
| Question | Answer |
|---|---|
| Nursing Diagnosis Who creates/determines them? | The Nurse creates them. The RN's examine and analyze the client database to formulate the nursing diagnosis. |
| What is the role of the LPN in creation of Nursing Diagnoses? | Report information that suggests problem-focused or potential health problems. |
| Categories of Nursing Diagnosis?* | 1. Problem-focused nursing diagnosis 2. Risk nursing diagnosis 3. Health promotion nursing diagnosis 4. Syndrome nursing diagnosis PG. 23 |
| Problem- focused nursing diagnosis | Identify existing problems or an "undesirable response to a health condition/life process" Ex: Urinary Retention or Anxiety |
| Risk nursing diagnosis | Involve clinical judgments about "the vulnerability of an individual, family, group, or community for developing an undesirable response to health conditions/life processes" *DO NOT include DATA (undeveloped or incomplete) Ex: Risk for Injury chem pol. |
| Health promotion nursing diagnoses | Reflect clinical judgment of a client's motivation and behavior to increase well-being and "actualize human health potential" *someone who desires a higher level of health Ex: Readiness for enhanced urinary elimination |
| Syndrome nursing diagnosis | Describe specific diagnoses that occur as a group and are best addressed as a group with similar interventions |
| Seven syndrome diagnoses | 1. Chronic Pain Syndrome 2. Disuse Syndrome 3. Frail Elderly Syndrome 4. Post-trauma Syndrome 5. Rape Trauma Syndrome 6. Relocation Stress Syndrome 7. Sudden Infant Death Syndrome |
| Collaborative problems | Denote complications with a physiologic origin and DIFFER from NURSING DIAGNOSIS, which address client responses to various circumstances and are managed by nursing interventions. |
| Medical vs. Nursing Diagnosis | Medical- deals with disease or medical condition Nursing- deals with human response to actual or potential health problems and life processes |
| Establishing Outcome Statements | SMART Specific Measurable Agreed upon by all parties Realistic Time bound *He or she should relate them directly to the nursing diagnoses and make them clear and specific. |
| When does the Nursing Process begin? | When a client is present with multiple healthcare needs that the caregiver must approach in an organized, systematic manner to provide efficient and effective care. |
| Purpose of Care Plan | Identifies interventions or actions for achieving the outcomes |
| Care Plan Development | 1. Help identify nursing interventions for specific nursing or medical diagnosis 2. They save time by providing general suggestions for common conditions 3. Provides a means to communicate to all shifts of nursing personnel |
| Subjective vs. Objective Data | Subjective- "symptoms" info from clients point of view (feelings, perceptions, and concerns) Objective- "signs" obtained through observation, physical examinations, and laboratory and diagnostic testing |
| Importance of Baseline Data | It allows the team to compare information before and after implementation of the care plan to determine if the interventions are working |
| Maslow's Hierarchy of Needs | 1. Physiological needs 2. Safety and security needs 3. Love and belonging needs 4. Esteem and self-esteem need 5. Self-actualization needs |
| Physiological needs | (Lvl 1)- Breathing/food/water/sex/sleep/homeostasis/elimination |
| Safety and security needs | (Lvl 2)- Security of body/employment/resources/morality/family/health/property |
| Love and belonging needs | (Lvl 3)- Friendship/family/sexual intimacy |
| Esteem and self-esteem need | (Lvl 4)- Self-esteem/confidence/achievement/respect of others/respect by others |
| Self-actualization needs | (Lvl 5)- Morality/creativity/spontaneity/problem-solving/lack of prejudice/acceptance of facts |
| How to use the Mini-Mental Status Exam | It is a set of questions for screening cognitive function. The test takes only about 10 minutes but is limited because it will not detect subtle memory losses, particularly in well-educated patients. |
| What is the Mini-Mental Status Exam used for? | For patients who wander or have known dementia *determines cause and nature of wandering, which leads to effective intervention selection |
| Electromagnetic therapy | Promotes healing using electricity, magnets, or both. *Microcurrent therapy: low-intensity electrical currents to alter cellular physiology (non-healing fractures and to relieve pain) |
| Relflexology | Is a complementary health practice in which manual pressure is applied to the feet and hands. *7,000 nerve endings linked to body organs and tissues |
| Biofeedback | Is a mind-body technique in which an individual voluntarily controls one or more physiologic functions, such as body temp, HR, BP, and brain waves *a machine determines success |
| Massage Therapy | Involves applying pressure and movement to stretch and knead soft body tissues *relief from discomfort/improved mobility or functional use of affected parts of the body |
| Magnet Therapy | Is an alternative medical practice that uses static (unmoving) magnets to alleviate pain and other health concerns. Therapeutic magnets are typically in bracelets, rings, or shoe inserts. Though magnetic mattresses and clothing are also on the market |
| Fall Prevention Strategies* | Fall prevention involves identifying and managing a patient's underlying fall risk factors and optimizing the physical design and environment of the health care agency. ... PG. 342-Table |
| Seizure Safety (Response) | 1. In first 2 minutes establish & protect airway when patient loses consciousness 2. Provide noninv. airway protection & gas exchange + head positioning/administer O2 3. O2 Saturation, BP, HR q2 min 4. IV Route for emergency meds 5. Subsides, Intubate |
| Three phases to a seizure (Education) | 1. Aura-the start of a partial seizure 2. Ictus- "attack" involving a series of muscle contractions (tonic and clonic contractions) 3. Postictal "after the attack" the aftereffects of a seizure (arm numbness/altered consciousness/partial paralysis) |
| Seizure Safety (NAP) | -The patient's prior seizure history -Taking immediate actions in the event of a seizure (not trying to restrain, nothing in the mouth) -Informing the nurse immediately when seizure activity develops -Observing the patient's seizure pattern |
| Bathroom Safety | -Functional locks/nonskid mats/nonslip surface or rug (nonskid backing)/avoid slippery bath oils/at least 1 grab bar within reach/no towels on grab bars/stable stool in shower or chair, handheld sprayer/hot&cold marked, water heater 48.8C(120F) or lower? |
| Home Medication* | *Too Long* PG. 1103-1105 |
| Vitamin Safety | -Estimated average requirement -Recommended dietary allowances (RDAs) -Adequate intake (AI) -Tolerable upper intake level (UL) |
| Estimated average requirement | Is the intake that meets the estimated need of 50% of individuals in a specific group |
| Recommended dietary allowances (RDAs) | Represent the levels of essential nutrients necessary to meet the needs of most healthy persons |
| Adequate intake (AI) | Is set; it is the amount of a nutrient thought to meet or exceed requirements |
| Tolerable upper intake level (UL) | Is the highest level of daily nutrient intake that is likely to pose no risk of adverse health effects |
| Home Environment Safety* | *Too Long* PG. 1091-1095 |
| Fire Safety | RACE |
| R.A.C.E. | R-rescue patient from immediate injury by removing from area or shielding from fire A-activate fire alarm immediately C-contain fire (close all doors/windows, turn O2 off/electrical equipment, wet towels on base of doors E- evacuate patients |
| Alternatives to Physical Restraints | 1. Stress-reduction techniques (back rub, massage, and guided imagery) 2. Diversional activities (puzzles, games, music therapy, pet therapy, activity apron, performing purposeful activity) |
| Nursing Process | 1. Assessment 2. Diagnosis or analysis 3. Planning 4. Implementation 5. Evaluation |
| Assessment | Collect/organize data, determine client safety |
| Diagnosis or analysis | Analyzes data to identify and define health problems that independent or physician-prescribed nursing actions can prevent or solve |
| Planning | Setting priorities, defining expected (desired) outcomes (goals), determining specific nursing interventions, and recording the plan of care |
| Implementation | Means carrying out the written plan of care; performing the interventions' monitoring the client's status; and assessing and reassessing the client before, during, and after treatment |
| Evaluation | Assessment and review of the quality and suitability of care given and the client's responses to that care |
| Assessment of Restrained Patients* | 1. Identify- two; birthday/name/medical record # 2. Assess for underlying cause(s) of agitation and cognitive impairment leading to patient-initiated medical device removal PG. 353 |
| Applying Physical Restraints/Belt Restraints* | *Too Long* PG. 355-357 |
| Restraint-Free Environments* | *Too Long* PG. 350-351 |
| Restraint Orders | The use of mechanical or physical restraints requires a licensed health care provider's order and must be based on a face-to-face patient assessment. A patient's or family caregiver's informed consent is necessary in the long-term care setting. |
| Communication with patients who have Cognitive Deficits* | Their family caregivers need help to make adaptations to preserve the client's abilities to function safely within their homes. Two common cognitive conditions affecting clients in the home are dementia & depression PG. 1096-1097 PG. 79-82 |
| Making changes in the Environment of a Patient with Cognitive deficits* | *Too Long* PG. 1098-1099 |
| Alternative Medical Systems | Those whose theories of healing and practice evolved from other cultures |
| Alternative Therapies | Non-orthodox methods with no current proven basis for their effectiveness at promoting health |
| Integrative Medicine (Complementary Medicine) | A combination of conventional medical practice with nontraditional physical and nonphysical approaches for which there is some scientific evidence of safety and effectiveness |
| Patients seeking (nontraditional medicines/therapies) | If the principle of "First, do no harm" prevails and if the alternative therapy is not dangerous or unhealthy, it should be tolerated or even supported if it provides something perceived by the individual as being beneficial. |
| Holistic Care Concepts | Is complete or total patient care that considers the physical, emotional, social, economic, and spiritual needs of the person, his or her response to illness and the effect of the illness on the ability to meet self-care needs. |
| Purpose behind National Patient Safety Goals | Improve patient safety. The goals focus on problems in health care safety and how to solve them. |
| Why it is important to report the use of OTC and herbal remedies to a health care provider? | Herbal therapy is not regulated like pharmaceutical drugs are in the United States. Because herbs are classified as dietary supplements, they are not held to the same standards of unified dosages, safety, and efficacy as drugs. |
| Why it is important to report the use of OTC and herbal remedies to a health care provider? (2) | Herbal therapy is one of the greatest risk factors for adverse effects when combined with other conventional treatments such as drugs. |
| Identifying patient teaching needs | 1. Learning Styles: cognitive, affective, or psychomotor PG. 79 2. Age and Developmental Level: pedagogy, andragogy, or gerogogy PG. 79-80 |
| Reporting changes in patient condition | Initial and ongoing assessment is essential to the provision of nursing care |
| Patient Safety | 1. Two ways to identify a patient 2. Safety begins with a patient's immediate environment 3. Always be alert to conditions within a patient's environment that poses risks for patient injury |
| Electrical safety – responding to someone who has suffered electrical shock | PG. 1091 1. Power off electrical source & assess for pulse 2. Electricity is disconnected, provide appropriate assistance 3. Notify emergency personnel/patient's health care provider 4. Patient with pulse/alert/oriented, vital signs/burn injury |
| Appropriate use of side rails | Handrails installed along stairways provide security for clients with visual, balance, and coordination problems PG. 345 |
| Patient falls (causes) | Multifactorial. 1. Intrinsic Factors: co-morbidities, muscle weakness, and urinary incontinence increase 2. Transient Factors: postural hypotension, polypharmacy, and use of high-risk medications 3. Extrinsic Factors: poor lighting, slippery floor |
| Reducing stress when implementing change in a patient’s home environment | *Too Long* PG. 1086 Respect the concept of personal space. Making chances too rapidly without a client's consent causes more problems than benefits. |
Created by:
Megan123456
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