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Test 4 Nursing
NursingProcess,Infection Prevention,Nutrition,Stress
| Question | Answer |
|---|---|
| Is an active,organized,cognitive process used to carefully examine one's thinking and the thinking of others | Critical thinking |
| knowledge based on research or clinical expertise,makes you an informed critical thinker | Evidence based knowledg |
| Involves evaluating the solution over time to make sure that it is effective | Problem Solving |
| A product of critical thinking that focuses on problem resolution. | Decision Making |
| Process of determinating a clients health status after you assign meaning to the behviors,physical signs and symptoms presented by the client | Diagnostic Reasoning |
| The process of drawing conclusions from related pieces of evidence | inference |
| Careful reasoning so that you choose the options for the best client outcomes on the basis of the clients condition and the priority of the problem | Clinical decision making |
| A judgement about the likely corse of events and outcome of the diagnosed problem considering any health risks the client has included knowledge about usual patterns of any diagnosed problem | Prognosis |
| a five step clinical decision making approach that includes assessment,diagnosis,planning, implementation and evluation used to diagnosis and treat human responses to actual or potential health problems | Nursing Process |
| A visual representation of client problems and intervntions that shows their relationship to one another. | Concept Map |
| The processof purposefully thinking back or recalling a situation to discover its purpose or meaning. | Reflection |
| Five steps to testing research questions problem identification, collection of data, formulation of a research question or hypthesism testing the question or hypothesis, evaluating the results of the test or study | Scientific Method |
| The deliberate and systematic collection of data to determine a clients current and past health status and functional status and to determine the clients present and past coping patterns | Assessment |
| What are the two steps of assesment? | 1)Collection and verfication of data from a promary source(the client) and the secondary source(family,medical record, health profession) |
| What are the two steps of assessment? | 2. The analysis of data as a basis for developing nursing diagnoses,identifying collaborative problems, and developing |
| What is the purpose of assessment? | To establish a database about the clients percieved needs,health problems, and repsonses to these problems. In addition data revals related experiences,health practices goals,values,expectations. |
| A professional nurse's approach to identify,diagnosis and treat human repsonses to health and illness | Nursing Process |
| Information that you obtain through use of the senses | Cue |
| Judgement or interpretation of cues | Inference |
| A Client crying is an expample of a 1______ that possible implies fear or saddness which is 2_______ | 1)Cue & 2) inference |
| Functional health patterns | GOrdons 11 Typology(theoreticcal framework or practice standard in structured database format |
| 11 Typology functional heath patterns | Helath perception-heathmanagement, Nutritional-metabolic,Elimination,Activity-Exercise, Sleep-rest,Corgnitive-perceptual,Self Perception-Self Concept,Role-relationship,Sexuality-reporductive,coping-stress tolerance,value-belief pattern |
| The clients verbal descriptions of their health problems only clients provide this type of information that usually include feelings preceptions, and self report of symptoms | Subjective Data |
| Observations or measurements of a clients health status measurement is based on a accepted standard or known charactericts of behaviors | Objective Data |
| Organized conversation with a client which gives you the opportunity to introduce your self establish a caring therapeutic relationship Get insigh about cliebnt, determine client goals, obtain cues | Interview |
| What are the phases of interview process? | Orientation phase, Working phase and termination phase |
| Includes data about the clients current level of wellness, including a review of body systems, family and health history, sociocultural history, spiritual health and mental and emtional reactions to illness | Nursing Health History |
| Questions that limit the clients answers to one or two words such as Yes or No or a number or frequency of a symptom | Close ended question |
| Questions that prompts clients to describe a situation in more than one or two words | Open ended question |
| Includes active listening prompts such as all right go on and uh-huh indicating that you have heard what the client says and are attentive to hear the full story encouraging more detail | Back channeling |
| A systematic method for collecting data on all body systems | ROS Review of symptoms |
| _________of assesment data is the comparison of data with another spource to determine data accuracy | Validation |
| Involves recongnizing patterns or tends in the clustered data,comparing them with standards and then coming to a reasoned conclusion abpout the clients response to a health problem | Data Analysis |
| The identification of a disease condition based on specific evaluation of physical signs symptoms the clients medical history and the results of diagnostic test and procedures | Medical Diagnosis |
| A clinical judgement about the individual,family, or community to response to actual and potential health problems or life processes | Nursing Diagnosis |
| An actual or potential physiological complication that nurses monitor to detect the onset of changes in a clients status | Collaborative Problem |
| Nursing in terms of client problems | Client centered problems |
| To develop refine and promote a taxonomy of nursing diagnosistic terminology of general use of professional nurses,it was named this to better reflect the internawtional utility of nursing dagnosis for the global health community | NANDA international |
| the clinical criteria or assessment findings that support an actual nursing diagnosis | Defining characteristics |
| Objective and subjective signs and symptoms or risk factors that lead to a diagnostic conclusion | Clinical Criteria |
| Describes human reponmses to health conditions/life processes that will possibly develop in a vulnerable individual,family or community | Risk nursing diagnosis |
| describes human repsonses to health conditions or life processes that exist in an individual,family or communbity | Actual Nursing Diagnosis |
| A clinical judgement of a persons familys or communitys motivation and desire to increase well ebing and actualize human health potential as exposed in their readiness to enhance specific health behaviors | Health Promototion Nursing Diagnosis |
| describes human respones top level of wellness in an individual,family or community that have a readiness for enhancement | Wellness nursing diagnosis |
| The name of the nursing diagnosis as approved by NANDA internation, it describes the essence of a clients response to health conditions in as few words as possible | Diagnostic Label |
| A condition or etiology identified from the clients assessment data it is associated with the clients actual or potential reponses to the health problem and can change by using nursing interventionsq | Related factors |
| The nursing diagnosis is always withing the domain of nursing practice and a condition that responds to nursing interventions | Etiology |
| The third stepo of nursing process which is a category of nrusing behaviors in which a nurse sets client centered goals and expected outcomes and plans nursing interventions | Planning |
| the ordering of nursing diagnoses or client problems using notions of urgency and or importance to establisgh a preferential order for nursing actions | Priority Setting |
| An aim,intent or end. A broad statement that describves the desired change in a clients condition or behavior | Goal |
| A specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function | Client centered Goal |
| Measurable criteria to evaluate goal acheivements | Expected Outcomes |
| An objective behavior or response that you expect a client to achieve in a short time, usually less than one week | Short-term goal |
| An objective behavior or response that expect a client to achieve over a longer period,usually over several days,week, or months | Long term Goal |
| an individual family or community state bheavior or perception that is measurable along a contrinuum in response to a nursing intervention | Nursing senstive client outcome |
| Actions that nurse intitates these do not require direction or an order from another health care professional | Independent Nursing Intervention |
| Actions that require an order from a physician or abnother health care professional based on the physcians or health care provders repsonse to treat or manage a medical diagnosis | Dependent Nursing Interventions |
| AKA interdepedent nrusing interventions are therapies that require the combined knowledge skills and expertise of multiple health care professionals | Collaborative Interventions |
| Enhances the continity of nursing care by listing specific nursing interventions needed to achiece the goals of care | Nursing Care Plan |
| The reason that you chose a specific nursing action, based on supporting evidence | Scientific Rational |
| multidisplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition | Clinical Pathways |
| A process in which you seek the expertise of a specialist such as your nursing instructior to indentify ways to handle problemsin client management or the planning and implementation of therapies | Consultation |
| The name of the nursing diagnosis as approved by NANDA internation, it describes the essence of a clients response to health conditions in as few words as possible | Diagnostic Label |
| A condition or etiology identified from the clients assessment data it is associated with the clients actual or potential reponses to the health problem and can change by using nursing interventionsq | Related factors |
| The nursing diagnosis is always withing the domain of nursing practice and a condition that responds to nursing interventions | Etiology |
| The third stepo of nursing process which is a category of nrusing behaviors in which a nurse sets client centered goals and expected outcomes and plans nursing interventions | Planning |
| the ordering of nursing diagnoses or client problems using notions of urgency and or importance to establisgh a preferential order for nursing actions | Priority Setting |
| An aim,intent or end. A broad statement that describves the desired change in a clients condition or behavior | Goal |
| A specific and measurable behavior or response that reflects a clients highest possible level of wellness and independence in function | Client centered Goal |
| Measurable criteria to evaluate goal acheivements | Expected Outcomes |
| An objective behavior or response that you expect a client to achieve in a short time, usually less than one week | Short-term goal |
| An objective behavior or response that expect a client to achieve over a longer period,usually over several days,week, or months | Long term Goal |
| an individual family or community state bheavior or perception that is measurable along a contrinuum in response to a nursing intervention | Nursing senstive client outcome |
| Actions that nurse intitates these do not require direction or an order from another health care professional | Independent Nursing Intervention |
| Actions that require an order from a physician or abnother health care professional based on the physcians or health care provders repsonse to treat or manage a medical diagnosis | Dependent Nursing Interventions |
| AKA interdepedent nrusing interventions are therapies that require the combined knowledge skills and expertise of multiple health care professionals | Collaborative Interventions |
| Enhances the continity of nursing care by listing specific nursing interventions needed to achiece the goals of care | Nursing Care Plan |
| The reason that you chose a specific nursing action, based on supporting evidence | Scientific Rational |
| multidisplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition | Clinical Pathways |
| A process in which you seek the expertise of a specialist such as your nursing instructior to indentify ways to handle problemsin client management or the planning and implementation of therapies | Consultation |
| fourth step of nursing process the nurse intiates interventions that are most liekly to achieve the goals and expected outcomes needed to support or improve the clients health status | implementation |
| any treatment based upon clinical judgement and knowledge that a nurse performs to enhance client outcomes | nursing intervention |
| interventions are treatments performed through interactions with clients | Direct Care |
| Interventions are treatments performed away from the client but on behalf of the client or group of clients | Indirect Care |
| OR protocol is a document that quides decisions and interventions for specific health care problems or conditions | Clinical Guideline |
| a preprinted document contained orders for the conduct of routine therapies,monitoring guidelines, and or diagnostic procedures for specific clients with identified clinical problems. | Standing Order |
| Activities usually performed in the course of a normal day including ambulation eating dressing bathing brushing the teeth and grooming | Actvities of Daily Living |
| includes skills such as shopping preparing meals writing checks and taking medications | Instrumental activites of daily living IADLS |
| a harmful or unintended effect of a medication diagnostic test or therapeutic intervention | Adverse Reaction |
| plans representing the contributions of all disciplines caring for a client | Interdisplinary Care Plans |
| Promote health and prevent illness to avoid the need for acute aor rehabilitative health care | Preventative Health Nursing |
| Clients and families invest time in carrying out required treatments | Client adherance |
| The final step of the nursing process is crucial to determine whether after application of the nursing process the clients condition or well being improves | Evaluation |
| you conduct evaulative measures to determine if you met __________ not if nursing interventions were completed | Expect Outcomes |
| the minumum level of care accepted to ensure high quality of care to clients | Standard of Care |
| interchangeable terms that describe an approach to the continuous study and omrpovement of the processes of prividing health care services to meet the needs of clients and others | Quality improvement and Performance improvement |
| a term for managaing the individual clinical outcomes of clients as a result of prescribed treatments | Outcomes Management |
| the condition to be achieved as a result of care delivery or prescribed treatment | Outcome |
| What is the overall goal of the Nursing Process? | To diagnosis and treat human responses to actual and potential health problems |
| what are the five components of the nursing process? | Assessment,Diagnosis,Planning,Implementation and Evaluation |
| What do you do in the assessment phase? | gather information about the clients condition |
| What do you do in the diagnoses phase? | Identifiy the clients problems |
| What do you do in the implementation phase? | Perform the nursing actions identified in planning |
| What do you do in the planning phase? | Set goals of care and desired outcomes and identify appropriate nursing actions |
| What do you do in the evaluate phase? | Determine if the goals were met and outcomes acheived |
| an experience a person is exposed to through a stimulus or stressor and how that experience is perceived | Stress |
| Disruptive forces operating within or on any system | stressor |
| how people interpret the impact of the stressor on themselves of what is happening and what the are able to do about it | Appraisal |
| results when stress overwhelms a person existing coping mechanisms and disequilibrium occurs | Crisis |
| if symptoms of stress persists beyond the duration of thye stressor a person has expereinces this | Trauma |
| the arousal of thye sympathetic nervous system is referred to as this | Fight or flight response |
| this control the heart rate blood pressure and respiration | Medula Oblongata |
| this continuously monitors the physiological status of the body through connections with the sensory and motor tracts | Reticular Formation |
| produces hormones necessary for the adaptation to stress such as ACTH which in turn produces cortisol | Pituitary Gland |
| a three stage reaction to stress that describes how the body responds to stressors through the alarm reaction and resistance stage and the evhaustion stage it is triggered by a physical or indirectly by physchological event | GAS general adaptation syndrome |
| pituitary gland communicates with the hypothalmus these hormones act like morphine or opiates that produce a sense of well being reduce pain | endorphins |
| rising hormone levels result in increased blood volume,blood gluclose level, epinephrine, and norepinephrine amounts heart rate,blood flow to muscles,oxygen intake and mental alertness | Alarm reaction |
| the body stabilizes and responds in an opposite manner to the alarm reaction hormone levels heart rate blood pressure and cardiac poutput return back to normal and the body repairs any damage that has occure | Resistance Stage |
| the body is no loner able to resist the effects of the stressor and when the body has depleted the energy necessary to maintaint adpatation the physiological repsonse has intersified but with a compromised energy level adaptation to stress diminishes | Exhaqustion stage |
| evaluationg an event for its personal meaning | Primary Appraisal |
| if stress is present this focuses on possible coping stratgeis | Secondary Appraisal |
| persons effort to manage psychological stress | Coping |
| the purpose of which is to reulate emtional distress and thus give a person protection from anxiety and stress | Ego Defense Mechanisms |
| making up for a deficency in one aspect of self image by strongly emphasizing a feature considered an assest | Compensation |
| unconciously repressing an anxiety producing emtional conflict and trasnforming it into nonorganic symptoms | conversion |
| avoiding emtional conflicts by refusing to conciously acknowledge anything that causes intolerable emtional pain | Denial |
| transferring emtions ideas or wishes from a stressful situation to a less anxiety producing substitute | Displacement |
| Patterning behavior after that of another person and assuming that person qualities characterstics and actions | Identification |
| experiencing a subjective sense of numbing and a reduced awareness of ones surroundings | Dissociation |
| coping with a stressor through actions and behaviors associated with an earlier development period | Regression |
| a person experiencing witnessing or being confronted with a traumatic event and responding with intense fear helplessness or horror | Acute stress disorder |
| damaging stress | distress |
| stress that protects health | eustress |
| recurrent and itrsuive recollections of the event | Flashbacks |
| occurs as a person moves through lifes stages | Developmental crisis |
| provoked by an external source such as a job change motor behicle crash or death | Situational crisis |
| occurs as a result of chroinic stress it is a syndrome of emtional exhaustion depersonalization of others and perceptions of reduced personal accomplishment resulting from intense involvement with people in a care giving environment | Burnout |
| lumbar puncture | LP |
| left upper lobe | LUL |
| left upper quadrant | LUQ |
| m,min,m | minim |
| MCG | microgram |
| MCV | mean cell volume |
| mg | milligram |
| ml | millileter |
| mm | milimeter |
| MRI | magnetic resonance imaging |
| MS | multiple sclerosis |
| NPO | nothing by mouth |
| NS | normal saline |
| O2 | oXYGEN |
| OOB | OUT OF BED |
| ORIF | OPEN REDUCTION AND INTERNAL FIXATION |
| OT | OCCUPATIONAL THERAPY |
| PACO2 | PARTIAL PRESSURE OF CARBON DIOXIDE(ARTERIAL BLOOD) |
| PaO2 | partial pressure of oxygen(arterial blood) |
| pc | after meal |
| pe | Pulmonary embolism;physical examination |
| PEEP | positive and expiratory pressure |
| PEG | pneumoencephalography |
| per | through,by way of |
| PEERLA | pupils equal round and reactive to light and accomdation |
| PET | positrom emission tornography |
| pH | hydrogen ion concentration |
| pm | evening |
| POz | partial pressure of oxygen |
| PO | orally |
| ppd | purified protein derivative |
| pm | parts per million |
| p.r.n | when required as often as necessary |
| PTT | partial thromboplastin time |
| q | every |
| q2h | every two hours |
| 1gr- | 60 mg |
| 1gm= | 15gr. |
| 1cc | 1ml |
| 4 or 5 ml | 1tsp |
| 1ml | 15 or 16 gtts |
| 30 ml | 1 ounce |
| 3 tsp | 1tbl |
| 2bl | 1 ounce |
| 500 ml | 1pt |
| 1000ml | 1 liter |
| 1 liter | 1quart |
| 1000ml | 1quart |
| 2.2lb | 1 kilogram |
| ss | 1/2 |
| i | 1 |
| 1 l | 1000ml |
| gr 1/4 | 15mg |
| gr1/6 | 10mg |
| gr 1/150 | 0.4mg |
| never round the blood thinning medication | heparin |
| three nursing diagnosis for stress | Sress overload, caregive role strain,anxiety,decreased enery field, ineffective coping |
| identify stress management techniques | exercise,support systems, time management, journaling,progressive muscle relaxation |
| what is the difference between medical asepsis and surgical asepsis? | Surgical-sterile technique that prevents contamination of an open wound, serves to isolate the operative area from the unsterile enviroment and maintains a sterile field medical asepsis used to reduce number or organisms present and prevent transfer |
| Discuss the principle sterile object remians sterile only when touched by another sterile object | Sterile object remains sterile on when touched by another sterile object. sterile touching cleans is contaminated. sterile touching contaiment becomes contaminate. or the sterile state is questionable when broken or torn package |
| Discuss the principle only sterile objects may be placed on a sterile field | all items are properly sterilized before use. sterile objects are kept in clean dry storage areas packages must be dry and intact |
| Discuss the principle a sterile object or field out of the range of vision or an object held below a persons waist is contaminated. | Never turn ur back on asterile field or away from tray contamination can occur accidentally by dangling piece of clothing. ANY OBJECT HELD BELOW THE WAIST IS CONTAMINATED keep objects in front with hands as close as possible |
| discuss the principle a sterile object or field becomes contaminated by prolonged exposure to air. | avoid activities that may breate air current. open package as close to sterile field. do not talk cough or sneeze over sterile field minimize number of people walking in sterile area |
| Discuss the principle when a sterile surface comes in contact with a wet, contaminated surface the sterile object or field becomes contaminate by capillary action | is sterile package becomes wet dispose of. if moisture leaks through a sterile package it is contaminated any spill of sterile solution is a contamination |
| Discuss the principle fluid flows in the direction of gravity | a sterile 0object becomes contaminated if gravity causes the contaminated liquid to flow over the objects surface. hold hands above elbows when surgical srub dry from fingers to elbows with hands held up |
| duscuss the principle the edge of a sterile field or container are considered to be contaminated | a 2.5 cm 1 inch border around the drape is considered to be contaminated the edge of sterile containes become exposed to air after opened and thus are contaimanted after u remove forcieps or sterile needle it must not touch containers edge contaimanted |
| Describe the chain of infection | an infectious agent of pathogen-aresovior or sourth of growth-a portal exit from resovior-a mode of transmission-a portal entry to a host-a susceptible host |
| Discuss the various factor that affect a person susceptibility to infection | Age nutritional status prescence of chronis disease trauma and smoking. |
| Why is age a suspectability for infection | infants have an immature defense against infection the young or middle aged have a refined defense against infection and and older adults loose skin tugor and loose function or urinary system and lungs |
| why is notritional status a suspectiablity to infection | a reduction in the intake of nprotein and other nutrients such as carbs and fats reduce the bodys defenses against infection and impairs wound healing |
| why is stress a suspectiability to infection? | continued stress leads to exhaustion in which the energy stores are depleted and the body has no resistance to inavding organsisms..elevated cortisol levels result in decrease resistance to infection |
| why is disease process a susptability to infection? | clients with diases of the immune system are at a particular risk for infection. leukemia aids lynphoma and aplstic anemia and with chronic ndiseases such as diabetes or multiple scleriosis |
| why if medical therapy a suspetability to infection | adrenal corticosteriod prescribed for several conditions are antiflammatory drugs that cause protein breakdown and imflammatory imapired response to pathogens some cause side effects of bone marrow depression |
| identify common sources of infections | mosquitoes, unwashed hands, equipement used in the enviroment medical devices and performance of procedures, water, food,tick flea |
| methods of preventing infection in health and illness | asepsis, hand hygeine, cleaning disinfection and strilization of contaiminated objects, cleaning take isoloations and iolation precautions |
| Compare signs and symptoms of localized and systemic infections. | Localized the client usually experiences localized symptoms pain tenderness and reddness at wound site. Systemic an infection thqat affects the entire body fever aches chills nausea weakness |
| Sterlization 1-definition 2-methods 3-chemicals 4-other methods | complete elimanation or destruction of all microorganism including spores. steam under pressure,thylene oxide gas, hydrogen perioxide plasma, and cheamicals |
| Disinfection 1-def 2-method 3-chemiocals 3-other methods | elimanates many or all microorganisms with the exception of bacterial spores from inanimate objects types are disinfecton of surfaces and high level disinfection. accomplished by chemical or wet pasterazation alcohols,chlorines,hydrogen proxi |
| Antiseptics | agents that inhibits the growth of microorganism on the external surface of the body mercuric chloride,silver nitrate iodine and alcohol |
| Disinfectants | applied to non living objects to kill microrgansism alcohol, aldehyding, oxidizing agents, phenolics, quaternary amoniona compounds |
| Antimicrobials | kill or inhibit the growth of microorganisms include antibitoics and synthetically formed compunds expamples are antibiotics, antivirals, antifungals, anatiparasitics |
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