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fund of nursing
Test 2
| Question | Answer |
|---|---|
| hygiene | describes the activities in maintaing personal cleanliness and grooming. it promotes comfort, improve self image and decrease infection and disease |
| nurses responsibilities | provide the necessary assistance and at the same time promoting as much self-care as possible |
| factors that influence hygiene practices | 1.personal preference 2.culture and religion 3.economic status or living environment 4.developmental level 5.knowledge leve 5.health status/physical condition |
| ways in which health status affect self-care abilities | 1.Pain 2.limited mobility 3.sensory deficits 4.cognitived impaired 5.emotional disturbance |
| reasons we preform hygiene | it removes presperration, bacterid, ordor, and dead skin cells |
| what happens when you respect and accomodate a persons preference | it reflects your caring and promote maximum participation and independence |
| what are the stepts you need to do to promote self-care | 1.assesment 2.diagnosis 3.plan 4.intervention 5.evaluation |
| your assessment should include | the patients self-care abilities, health history, cognitive abilities, preferences and pratices, and other factors |
| what is a self-care deficit | someone who cannot preform one or more activity of daily living(ADL) |
| what are some self-care deficits | 1.bathing/hygiene 2.dressing/grooming 3.toileting 4.feeding |
| what is total self-care deficit | when a person cannot preform bathing/hygiene, dressing/grooming, toileting and feeding |
| when you make a plan what should it include | 1.identification (needs and abilities) 2.assistance (assist as needed) 3. modification ( modifide prosedures based on needs and tolerance) |
| what are the types of schedule hygiene care | 1.early morning 2.AM(morning)/after breakfast care 3.PM(afternoon) 4.HS(hours of sleep) 5.PRN |
| What is the skin | the largest organ in the body |
| what are the two layers of the skin | the epidurmas(the thick outer layer) and the dermis (thin inner layer) |
| What are the function of the skin | 1.protection 2.regulation 3.sentation 4.excreation 5.vitamin D production |
| What are the factors that affect the skin | personal hygiene, devemental stage,dampness, dehydration, skin disease, nutrition, jaundice, and insufficient circulation |
| waht should your assessment of the skin contain | subjectice data(things you are told), objective data(things you see/assess)like skin color and texture |
| pallor | paleness of the skin |
| tardor | level of hydration of the skin |
| tenting | when the skin is dehydraded and it stays up when it is pinched |
| erythema | redness of the skin |
| jaundice | yellow discoloration of the skin caused by impaired liver function |
| cyanosis | blush color caused by decreased peripherial circulation and decreased oxgenation of the skin.(in black people you would check the mouth) |
| prunitus (pa-right-ous) | itching |
| dry skin | tends to crack |
| odd skin colors | pallor,erythema(ere-thema), jaundice, cyanosis(cy-no-sis) |
| maceration (mas-a ray-sion) | is the softening of the skin from prolonged moisture |
| excoriation (ex-scar-e-a-sion) | the lost of the superfical layer of skin caused by enzymes in feces |
| abrasion | a rubbing away of the skin especially over bony area |
| pressure ulcer/decubitus ulcer | lesions caused by tissu compression |
| acne | inflammation of the subaceous glands |
| the over all goal for the skin | to keep the skin healthy and intacy |
| Interpersonal communication | communication between two or more people. its a process in which prople affect one another through the exchange of info |
| referent | what motivates the someone to talk |
| sender | initiate the conversation to deliver a message to another person |
| receiver | the person who receives the message |
| message | the content of the message |
| channels | how the message is communicated. the more channel you use the better |
| feedback | the message returned by the seder |
| interpersonal variables | factors that influence the communication 1.preception 2.values 3.beliefs |
| environment | the setting for the communication 1.distractions 2.timing 3.relevance |
| ways in which to mannage communication | 1.be aware of your motivation, beliefs and values 2.consider the verbal & nonverabl communication 3.use as many channel as possible 4.solicit feedback 5.active listening 6.manage the environment-pull up a chair and refuse interruption |
| kinesis | body movement |
| inorder for clients to understand what a nurse is saying what must the nurse do | 1.be simple, brief and direct 2.use examples to cleariify |
| what are some non-verbal communication | personal apperance, territoriality and personal space, posture and gaite, gesture, facial expression, and eye contact |
| empathy | the disire to understand and be sensitive to the feeling, belief, and situations of another preson. you are truely available to the pt, understanding, and able to help/do problem solving. requires listening, observe/pay att to nonverbal communication |
| sympathy | felling of compassion and pitty. |
| respect | be accepting of the pt and recognize their strengths |
| what should you NOT do in therapeutic communication | you should not give advice |
| the difference between a helping and a social realtionship is called | boundries |
| stages of helping relationship | 1.preorientation stage-what i am in right now. this is when you are able to learn and ask questions 2.orientation- this is when you meet the pt & set boundried 3.working phase- the active part of relationship 4. terimination-comclusion of relationship |
| enhance therapeutic communication | active listening; share observations, empathy, hope,and humor;using touch and silence |
| nontherapeutic communication | give opinion, change the subject, false reassurance, asking why, giving approval/disapproval, arguing |
| what are the reasons for documentation | it serves as a communication of the patients status and for legal documentation |
| what are the type of charting | 1.narrative charting-includes written sentences 2. soap charting-subjective data,objective data,assessment, and plan 3.soapier 5.pie charting-problem, intervention,evaluation 6.facus/dar charting 7.charting by exception and 8. computerized charting |
| advantage/disadvantage of narritave charting | advantage:easy to learn, easy to adjust and can explain in detail Disadvantage:time consuming, difficult to retrive info, contains irrelevent info, and can be unorganized |
| advantage of SOAP | advantage:all charting is aroung the patient, interdisciplinary, easy to track progress |
| advantage of pie chating | plan for care is incorporated in progress notes, outcomes included, daily review to determin progress, less redundancy, and easy adaptable to automated charting |
| advantage/disadvantage of facus/dar charting | advantage:can chart on any sig. area, concise,flexable,work well in falicies Disadvantages:not multidisciplinary, difficult to identify chronological order, progress notes may not realte to plan of care |
| what is charting by exception | a preprinted flowsheet of care. it assumes that unless a seperate entry is made all standards have been met and pt responded normaly |
| advantage of charting by exception | advantage:efficient, can take the place of car plan |
| computerized charting | all or part of the patients records are documented and maintained on the computer |
| advantage/disadvantage of computerized charting | Advantage:systemic approch, cause effective and increase quality of documentation, legible and accurate by promopting nurses for info |
| how to chart | accurate, cincise-short and to the point, complete, and specific |
| what to chart | assessment date. indepth assessment if any abnormalities, nursing actions taken,pt progress to plan of care,education provided,discharged needs |
| TO DOs in charting | make sure the chart have patient correct name and time, write legibly-black ink and everything is spelled correctly with correct grammer,draw line in empty spaces, date and time all entries, sign with legal name and title,document all serious situations |
| DONTs in charting | share password,correct error by-erasing/white out/crossing with X/scribbling out,mention incident report,alter pt records,name second pt,use negative languageor info about pt in records |
| if chart is unavailable | add info on first avb. line and start with current time and date, write "late entry" and reason, document care indecating time and sign the entry |
| how should a incident report be handled | it should only be completed by staff who witnessed or found the incident, should not be mentioned in nurses note(not discoverable) |
| what are the purpose of reports | provides for continuous care and exchange of information. |
| what are the type of reports | 1.face-to-face 2.tape-recorded 3.phone 4.computer printout 5.written |
| kardex | a condense reference tool that includes basic client care information. used during change-of-shift report and as aquick reference throughout the shift |
| what should you do when giving a change of shift report | 1.prepare-gather and organize data 2.present individual client information-age,name,sex,room number,and attending physician |
| S-BAR | S=situation, B=background, A=assessment R=recommendation |
| Disadvantage of SOAP | difficult to master, lengthy and time consuming,specific focused making it difficult to chart general info w/out IDing the problem |
| Disadvantage of pie chating | must read progress notes to determin plan of care, problem not ID diff to chart |
| Disadvantage of charting by exception | expensive to institute, not provention focused, not appropriate for falicities |
Created by:
lilastacia06
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