Term
Nursing Process
(What is it?) |
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Definition
-plan used to take care of patients' needs
-will be used in every field of nursing
-used as a problem-solving tool
-used to prevent potential problems
-has five interrelated components
-impacts nursing care plan and diagnosis
-requires critical thinking
-cycles in relationship to patient's health status |
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Term
Nursing Process
(Components) |
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Definition
-assessment
-bursing diagnosis
-planning
-implementation
-evaluation |
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Term
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Definition
-systematic and continuous collection of data to:
1, predict, detect, prevent, manage, and eliminate health problems and risk factors
2. clarify expected outcomes
3. identify interventions to achieve desired outcomes, promote health, and attain optimum function and independence |
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Definition
-what they tell you
-cannot be proved |
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-what you can see and measure
-can be proved |
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Definition
-analyzing data to draw conclusions to:
1. identify the need for referral to more qualified professional
2. clarify actual and potential health problems
3. determine resources and strengths
4. identify factors contributing to a problem
5. identify patterns from cues
6. form valid generalizations |
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Definition
-actual
-risk
-wellness
-possible
-syndrome |
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-potential problem
-definite
-proven |
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Definition
| -teach how to eliminate problem |
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Definition
-potential problem
-no supporting data |
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-nursing: based on conditions the nurse can legally treat
-MD: made by and treated by MD |
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Definition
-basic 2-part: problem + etiology (cause)
-ex: pain r/t surgical procedure
-basic 3-part: problem, etiology, + signs and symptoms
-impaired skin integrity r/t prolonged bed rest as evidenced by stage I pressure ulcer formation |
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Definition
-focus on prioritized problems and risk factors
-include initial, ongoing, and discharge considerations
-promote optimum function, independence, and health
-include patient in decision making and care
-achieve desired outcomes safely, efficiently, and be cost-effective
-provide teaching to help patient make informed decisions
-document progress and communicate continued care |
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Definition
-specific goals set by the RN
-based on the nursing Dx
-response expected to planned intervention
-include the patient and family
-end result on nursing care plan
-short or long-term |
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Definition
-assessing the appropriateness of the plan and patient readiness
-prioritizing, delegating, organizing, and coordinating care
-preparing the environment and equipment for safety and comfort
-determining the need for assistance
-performing interventions then reassessing for initial response
-making immediate changes if needed
-updating the care plan as needed |
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Definition
-assessing the patient to see if the goal was met
-planning for ongoing assessment, improvement, and patient independence
-discharging patient or modifying the care plan as needed |
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Definition
-assessment: immobile patient has 1 cmx2cm reddened, non-blanchable area on coccyx
-nursing Dx: impaired skin integrity r/t immobility as evidenced by stage I pressure ulcer
-plan/desired outcome: prevention of further breakdown and healing of damaged tissue by hourly turning and repositioning, barrier cream to protect tissue, prevent moisture build-up, and increase fluid intake as tolerated
-implementation: carry out above with CNA assist
-evaluation: stage I PU size decreased from 1x2 cm to 0.5x1 cm |
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Definition
-an active, organized, cognitive process used to analyze collected data, plan, and implement a solution and evaluate the outcome
-used to identify a potential or actual complex problem and use knowledge, research, and experience to prevent or fix it |
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Definition
-the RN is a novice with little clinical practice experience
-0-2 years experience |
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-the RN is able to analyze problems more independently
-2 years experience |
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-the RN is highly skilled
-able to explain to others
-trainers and teachers |
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Definition
-the RN is highly skilled
-able to explain to others
-trainers and teachers |
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Term
Critical Thinking Skills
(Why do we need them?) |
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Definition
-essential for safe practice
-prove competent nursing care
-effective way to manage care
-allows autonomous practice |
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Definition
-gather information about the problem
-consider what you already know about the problem
-combine knowledge and consider options on the best way to use it |
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-information gathering: collecting data
-trial and error: not a good idea with patients
-intuition: good guide with a lot of experience
-scientific method: using situations from controlled experiments |
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-identify the problem: priorities, Dx
-identify the purpose: solve the problem
-set criteria: end result? preserve? avoid?
-weigh the criteria: avoid sedation, confusion, constipation, injury, nausea
-seek alternatives: other options
-examine each alternative: cost
-project: picturing in mind, how you want it to end up |
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Term
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Definition
-conclusions drawn from many sources: lab results, nurse before you, nurses aid
-interpretation of patient needs
-requires continuing education
-part of the nursing process |
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Term
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Definition
-temperature (T)
-pulse/heart rate (P or HR)
-respiration (R)
-oxygen saturation (SaO2)
-blood pressure (BP) |
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Term
Vital Signs
(Normal vs Parameters) |
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Definition
-temperature: 35.7-37.2 C
-pulse: 60-100 BPM
-respirations: 12-20 breaths per minute
-SBP: 90-120 mm/Hg
-DBP: 60-80 mm/Hg
-SaO2: greater than or equal to 92% |
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Term
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Definition
-know patient's normal range
-compare to previous set
-control environmental factors
-use as guideline for medication administration
-recheck with change in patient condition
-ensure correct equipment size & type
-know medical history and current meds
-frequency based on patient condition and MD orders
-may be delegated to assistive staff |
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Definition
-represents the average body core temp
-average of heat produced minus heat lost
-controlled by hypothalamus
-affected by: age, exercise, hormones, circadian rhythm, stress, environment |
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Term
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Definition
-axilla: armpit
-oral cavity: mouth
-rectum: anus
-ear canal/tympanic membrane: ear
-temporal artery: forehead |
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Term
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Definition
-bladder
-esophagus
-pulmonary artery
-taken by catheters |
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Term
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Definition
-chill phase: onset of symptoms, increase in HR and R, chilling, shivering, cessation of sweating, pale, cool skin
-plateau phase: sweaty, warm skin, glassy eyed, increased HR, R, and thirst, lethargy, confusion, malaise, photosensitivity |
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Term
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Definition
-reusable for oral, axillary, rectal, tympanic, and temporal sites
-results in 2-30 seconds |
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Term
| Manual, Non-Mercury Thermometer |
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Definition
-reusable for oral, axillary, and rectal sites
-results in 1-2 minutes |
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Definition
-single or multiple use for oral, axillary, rectal, and forehead placement
-result times vary |
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Definition
-C=(F-32)x5/9
-ex: 104F-32x5/9=40 degrees C |
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Definition
-S1: occurs when mitral and tricuspid valves close after blood enters the ventricles; lub
-S2: occurs when the aortic and pulmonary valves close after blood is squeezed out of the ventricles; dub |
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Definition
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-midclavicular line around 4th or 5th intercostal space
-60 seconds |
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Definition
| -inner aspect of upper arm between bicep and tricep |
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Definition
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Definition
| -in the groove between thigh and groin |
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Definition
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| -along top of foot between tendons of big toe |
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Definition
-rate: beats per minute
-rhythm: lub dub
-strength: strong, weak, bounding, threading
-equality: one side same as other; always check two sites |
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Factors Affecting HR
(Increase) |
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Definition
-intermittent exercise
-fever/heat
-dehydration
-acute pain
-anxiety
-blood loss
-COPD
-sitting/standing
-medication |
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Factors Affecting HR
(Decrease) |
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Definition
-regular exercise
-hypothermia
-untreated severe pain
-lying down
-medication |
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Term
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Definition
-passive process
-autonomic control by brain stem
-phrenic nerve stimulates diaphragm
-diaphragm initiates lung movement
-inhalation of O2 from environment
-exhalation of CO2 from the body |
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Term
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Definition
-abdominal organs move down and forward
-diaphragm rises 1 cm
-ribs retract 1.2-2.5 cm
-inhalation of around 500mL of air |
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