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NUR 155 Exam One
| Term | Definition |
|---|---|
| What is the definition of the Nursing Process | The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients. |
| What is the acronym for the nursing process and what does each letter stand for. | ADPIE: Assessment, Diagnosis (nursing), Planning, Implementation and Evaluation |
| Clinical judgment modal | Recognizes cues Analyze cues Prioritize hypotheses Generate Solution Take action Evaluate outcome |
| Clinical Judgement | the ability to observe, think, prioritize, plan, act, and evaluate, "thinking like a nurse" |
| Critical Thinking | Application of knowledge and experience to identify pt problems and make judgment "higher level of thinking " |
| Clinical Reasoning | Ability to focus and filter clinical data. recognize what is most and least important. |
| Attributes required for successful clinical judgment | Strong knowledge base and proficient technical skills Early problem recognition Effective communication and trusting nurse patient relationships Previous experience, confidence, and INTUITION. Reflection |
| Environmental factors that influence clinical judgement skills | Task completion, Time pressure, Interruptions, Specialty area and autonomy. |
| Describing each part of the nursing process what is Assessment (assess) | Gather information( collecting data) Verify that the information collected is accurate and clear |
| Describing each part of the nursing process what is Diagnose | Identify and prioritizing the problem through the nursing diagnosis (NANDA approved) Interpret the information collected |
| Describing each part of the nursing process what is Planning | Set goals to solve the problem Prioritize the outcomes of care |
| Describing each part of the nursing process what is Implement | Reach those goals through performing the nursing actions Implement the goals set above in the planning stage |
| Describing each part of the nursing process what is Evaluate | Determine the outcome of the goals Evaluate the patients compliance Document the patients response to pain Modify and assess the need for change |
| Smart is the acronym used in the planning stage of the nursing process what does each letter stand for and what is it used for | S.M.A.R.T Specific, Measurable, Achievable, Relevant, Time frame |
| What type of data is collected during the assessment phase of the nursing process | Objective and Subjective |
| What is objective data | Can be proven (observed) Unbiased facts: thing that you can see hear, feel, auscultate, and measure |
| What is subjective data | Cannot be proven (what the patient says) opinions or biases |
| What is Maslow's Hierarchy of needs (list from bottom of pyramid to top) | Physiological needs-basic needs Safety and security- basic needs Love and belonging - psychological needs Self-esteem- psychological needs Self actualization- self- fulfillment needs |
| Physiological needs | Oxygen, water, food, elimination, temperature control, sex, movement, rest, comfort |
| Safety and Security | Safety and security from a physiologic and psychological threat; and protection, stability, and lack of danger |
| Love and Belonging | Affection, intimacy, support, and reassurance |
| Self-esteem | Self-worth, self-respect, independence, privacy, status, dignity, and self-reliance |
| Self-Actualization | Recognition and realization of one's potential, growth, health and autonomy |
| Clinical Judgment Modal: Recognize Cues | Identify relevant and important information from different sources (e.g., medical history, vital signs) |
| Clinical Judgment Modal: Analyze Cues | Organize and link the recognized cues to the client's clinical presentation |
| Clinical Judgment Modal: Prioritize Hypotheses | Evaluate and rank hypotheses according to priority ( urgency, likelihood, risk, difficulty, time, etc.,) |
| Clinical Judgment Modal: Generate Solution | Identify expected outcomes and use hypotheses to define a set of interventions. |
| Clinical Judgment Modal: Take Action | Implement the solution(s) that addresses the highest priorities. |
| Clinical Judgment Modal: Evaluate Outcome | Compare observed outcomes against expected outcomes. |
| Primary Data | Information that comes directly from the patient. |
| Secondary Data | Information that comes from family, friends, caregivers. also, data obtained pt charts, medical records, and lab results. |
| Independent nursing interventions | A nurse can perform independent interventions on their own without assistance from other medical personnel, e.g., routine nursing tasks such as checking vital signs. |
| Dependent nursing interventions | Some actions require instructions or input from a doctor, such as prescribing new medication. |
| Collaborative nursing interventions | Requires collaboration among healthcare professionals and unlicensed essence assistive personnel. Examples. Physical therapy. Home health care. Personal care? Spiritual counseling. Medication reconciliation. Palliative or Hospice care? |
| Attributes required for successful clinical judgment | • A strong knowledge base. • Proficient technical skills. • Early problem Recognition. • Effective communication. • Trusting relationship with patients. • Previous experience • . Confidence. • Intuition. |
| Adult Normal Vitals | Pulse: 60-100 Blood pressure: 100-120/60-80 Temp: 97.6-99.5 SPO2%: 95-100% RR: 12-20 Pain 0-10 scale |
| Afebrile | Maintaining normal body temp |
| Apnea | an absence of breathing; brain damage can happen after 4-6 min |
| Bradycardia | a slow heart rate, less than 60bpm |
| Bradypnea | a decrease in respiratory rate, less than 10 |
| Cyanosis | bluish discoloration of the skin and mucous membranes, caused by decreased oxygen levels in arterial blood |
| Dyspnea | difficult, labored breathing, usually with rapid, shallow pattern |
| Dysrhythmia | an irregular rhythm in the pulse, caused by an early, late, or missed heartbeat |
| Eupnea | normal respiration with a normal rate and depth for pts age |
| Febrile | elevated body temp |
| Heat exhaustion | profound sweating resulting in excessive water and electrolyte loss after environmental heat exposure |
| Heatstroke | Prolonged exposure to the sun or high environmental temperatures overwhelms the body's heat loss mechanism. This health emergency has a high mortality rate. |
| Hypercapnia | high levels of carbon dioxide |
| Hypertension vs Hypotension | Hyper: elevated blood pressure Hypo: decreased blood pressure |
| Hyperthermia vs Hypothermia | Hyper: high body temp Hypo: decreased body temp |
| Hyperventilation vs Hypoventilation | Hyper: overexpansion of the lungs -deep, rapid respirations often caused by stress or anxiety. Hypo: underexpansion of the lungs, characterized by shallow, slow respirations. |
| Hypoxemia | low oxygen levels in the blood |
| Korotkoff sound | The sounds for which the nurse listens when assessing blood pressure. |
| Auscultatory gap | during blood pressure measurement, absence of the Korotkoff sounds noted in some pts after the initial systolic pressure. |
| Orthopnea | difficulty in breathing when in positions other than upright |
| Orthostatic hypotension | a sudden drop of 20 mm Hg in systolic pressure and 10mm Hg in diastolic pressure when the patient moves from a lying to sitting to standing position. |
| Pulse deficit | the apical pulse rate exceeds the radial pulse rate |
| Tachycardia | an excessively fast heart rate greater that 100 |
| Tachypnea | an increase in RR to more than 24 in adults |
| Pyrexia | another term for fever |
| Febrile | a person with a fever |
| Afebrile | without fever |
| Fever sign and symptoms | loss of appetite/ anorexia headache malaise/feeling tired hot and dry skin flushed appearance thirst shivering generally unwell feeling |
| Pulse pressure | the difference between systolic and diastolic pressure. to calculate your pulse pressure, all you have to do is subtract the bottom number from the top number. |
| what will you do if you find a irregular pulse | check and listen to the apical pulse for 1 full minute |
| Chain of infection | Infectious agent Source Portal of exit Mode of transmission Portal of Entry Susceptible host |
| Health care-associated infections (HAIs) | acquired while the pt is receiving treatment in a health care facility. |
| How long should you wash your hands? | at least 20 seconds |
| Contact precautions | direct and indirect transmission MRSA, C.Diff, RSV, VRE, Hep A, Scabies, Herpes simplex virus Gloves and gown |
| Airborne precautions | small droplet transmission can spread a great distance and longer time than droplet. varicella(chicken pox), Rubeola(measles), tuberculosis, covid, N-95 mask gloves, gown, eye protection, and or face shield, negative pressure room |
| Droplet precautions | diseases transmitted through large droplets in the air (cough, sneeze talking) flu, mumps, rubella, and pertussis, streptococcal pharyngitis, scarlet fever, pneumonic plague, whooping cough surgical mask, 3ft spacing |
| Medical vs Surgical asepsis | Medical: clean technique Surgical: sterile technique |
| Disinfection vs Sterilization | D: destroys all pathogenic microorganisms except spores from inanimate objects. S: destroy all microorganisms including their spores. |
| WBC | 5000-1000 |
| Intrapersonal Communication | (occurring internally) positive and negative self-talk meditation and prayer |
| Interpersonal Communication | (occurring between two or more people) formal or nonformal |
| Phases of the nurse-patient helping relationship | orientation/introductory working termination |
| Essential components of professional nursing communication | respect, assertiveness, collaboration, delegation, advocacy |
Created by:
Dubrinak