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Unit 1 & 2
QSEN, Nursing Process, Assessment
75
Nursing
Not Applicable
09/07/2011

Additional Nursing Flashcards

 


 

Cards

Term
What does QSEN involve?
Definition
Quality, safe, patient-centered care. Must be evidence based. Provides knowledge, skills, & attitudes.
Term
QTPIES
Definition

quality improvement

teamwork/collaboration

patient-centered care

informatics

evidence-based practice

safety

Term
Quality Improvement
Definition

find problem in health setting

plan to improve

evaluate

Term
Teamwork/Collaboration
Definition

Nurse is continually w/ pt.

DR. is not.

Have to have opinions & recommendations

Term
Patient-centered Care
Definition

focus on pt.

cultures, values, etc.

Must take into consideration what they want.

Term
Informatics
Definition

Technology

 

xrays, computer systems, etc etc.

Term
Evidence-based practice
Definition
Everything done is backed up by reliable sources.
Term

What do pts base their rating of hospital on?

 

(not intentionally)

Definition

PAIN.

 

If pain in managed/manageable, pt is more likely to respond positively to their treatment.

 

Term

12 Basic Human needs

 

In order!

Definition

Oxygenation

Fluid/Electrolytes

Safety

Elimination

Nutrition

Rest & Activity

Sensory

Comfort

Sexuality

Spirituality

Human Interaction

Learning

Term

12 basic human needs

pneumonic

Definition

OFSENRSCSSHL

 

Our fellow students enter nursing realizing some classes sound simple; how laughable.

Term
T/F: Oxygenation only includes the respiratory system.
Definition

FALSE.

 

Oxygenation also includes proper circulation in pts.

 

Term
What is the main function of Oxygenation?
Definition
To keep brain alive.
Term
How long can the brain function without oxygen till it "dies"?
Definition
4 minutes.
Term

What is included in electrolytes?

Provide examples.

Definition

Na

Cl

Ca

Mg

K

 

-examples provided in class: Na= v8 juice, chips. K=banana

Term
What is included in safety as a human need?
Definition
Use of assistive devices, call light within reach, obstructions removed, disuse of polypharmacy (use of more than one doctor/pharmacy so records are inaccurate and possible meds could interact in a neg. way with each other)
Term
Elimination includes:
Definition

both bowel & bladder.

Biophysical.

 

Term
What is normal urine output?
Definition
30 mLs/hr
Term

Rest & Activity

-what's involved?

Definition

rest- good mood.

 

activity- work on weight bearing activities. build muscle/reinforce bones. water activities, etc.

allow for periods of rest and recovery

Term
Sensory: 6 senses
Definition
visual, auditory, kinesthetic, gustatory, tactile, olfactory
Term
What do older adults tend to do when problem/health issue (sensory) arises?
Definition

Older adults ADAPT TO DISFUNCTIONS.

They set the problem as a norm b/c they don't want to be a bother.

 

Ex. hearing- they attribute their hearing loss to old age and will not acknowledge it to a health professional.

Term
Why are tactile senses important, especially in older adults?
Definition

Older adults (as well as any other age) need to be able to tell the difference between hot/cold, sharp/dull, etc.

 

This avoids possible injuries (burns, cuts, etc.)

Term
Why is olfactory important?
Definition
need to be able to smell rotten food, burning smells, etc.
Term
Acute vs. chronic pain
Definition

acute- pain needs to be resolved

 

chronic- long term. Happy when pain is at 3 or less. (on pain numbers scale)

Term
T/F: Older adults are not at risk for AIDS/HIV.
Definition

FALSE.

 

Older adults are at more of a risk because they are new to the "dating scene" (spouses dying). Not accustomed to using condoms (raised on idea of only having "relations" with one person). Also more of a risk of UTIs.

Term
Why would spirituality be potentially important for the older adult?
Definition
Nearing the last of life. may have sudden onset of spirituality.
Term
What is continuity theory?
Definition

Continue to maintain values, habits, & behavior in old age.

 

*Assess normal habits before stating there is a problem.

Term
T/F: As adults get older, their cognitive function begins to decline.
Definition

FALSE.

 

Don't have cognitive decline. May take longer but do not lose function. Must be motivated to learn!

Term
Factors affecting motivation:
Definition

motivation

 relevance

 environment

readiness

 feedback (+)

involvement

support

Term
5 steps Nursing Process:
Definition

Assess

Diagnose

Plan

Implement

Evaluate

Term

What do we do with data during assessment?

 

(4 things)

Definition

collect

organize

validate

document

Term
What part of the nursing process are signs and symptoms in?
Definition
Assessment
Term
Signs vs. Symptoms
Definition

Signs- objective. What we can see; tangible; can't interpret.

 

Symptoms- subjective. Pt reports. Ex. nausea, headache.

Can't measure.

Term
What do we identify in diagnosing?
Definition
Abnormal findings, strengths of clients, health problems that can be prevented (vaccines)
Term

Which step are interventions in?

 

nursing process

Definition

Planning.

 

 

Term
What are important characteristics for interventions?
Definition
Organized, individualized, & goal directed.
Term
T/F: Interventions should be focused only on you as the nurse.
Definition

FALSE.

 

Interventions should be pt centered.

Develop individualized care plan.

Term

Prioritization of Human Needs

 

(levels)

Definition

Level 1: Oxygenation

2: fluid & electrolytes, nutrition, safety, elimination

3: rest & activity, sensory, comfort

4: learning, human interaction, sexuality, spirituality

Term
How are interventions written?
Definition
"The nurse will...."
Term
Why would an intervention be implemented?
Definition

to present new problem, to prevent worsening of existing problem.

 

INDIVIDUALIZE!

Term

SMART

 

what does it stand for and what does it relate to?

Definition

Specific

Measurable

Attainable

Reasonable

Timed

 

--Used as guidelines for GOALS.

Term
How are goals written/stated?
Definition
"The patient will..."
Term
Short term vs long term goals
Definition

short term: completed during shift that day

 

long term: 7 days or more. done by discharge (ex.)

 

Term
T/F: Patient care plans do not ever change while being implemented.
Definition

FALSE.

 

Care plans are fluid. They are constantly modified because the situation is always changing.

Term
When does discharge planning begin?
Definition
On admission!
Term
What do care plans include?
Definition

Basic needs & ADL's

Teaching

@ least 1 med

Term
What is the action phase of the nursing process?
Definition
Implementing
Term
last phase in np?
Definition

Evalutation

Did pt meet goals and to what extent? Continue, modify, or terminate plan of care?

Term
non compliance vs non adherence
Definition
Term
What does the general inspection include?
Definition

speech

mood

cleanliness

ambulation

obvious abnormalities

Term
Skin: Assess
Definition

Color (cyanosis, jaundice, erythema)

Moist/dry

Edema

Lesions

Integrity

Term
Stages of edema
Definition

+1: up to 1/4"

+2: 1/4" to 1/2"

+3: 1/2" to 1"

+4: ≥ 1"

Term
Where do you check for edema?
Definition

Extremeties- feet, hands.

if laying flat, butt.

 

Bath is a good time to inspect/assess.

Term
What do we look for with skin lesions?
Definition

Symmetrical moles

Malignant will be uneven and discolored.

Term
What do we assess for with skin integrity?
Definition

Temperature

texture

moisture

turgor

Term
What teaching is involved with skin integrity?
Definition
the importance of keeping skin dry & turning pts
Term
Turgor
Definition
skin elasticity
Term
time for tenting
Definition
<3 sec.
Term
Where to check tenting
Definition
forehead, arm, or chest
Term
Hair assessment:
Definition

cleanliness

equal distribution

quantity

quality

Term
Nail Assessment
Definition

Color

shape

thickness

texture

lesions

 

Term

Nails: Color

 

what to assess for

Definition

blanch test

check capillary refill-- <3sec.

Term

Nails: Shape

 

What to assess for

Definition

clubbing (result of chronic hypoxia)

-> greater than 180 ° angle.

caused by long term lack of O2

Term

Nails: Thickness

 

what to assess for

Definition

fungal infection?

Aging, trauma, bloodflow?

Term
Nails: Consistency & Texture
Definition
Hard, soft, or brittle
Term
How do you check for circulation/gas exchange abnormalities in clients with dark skin?
Definition

pallor-- oral mucosa (needs to be pink & moist)

 

yello/brown or ash gray skin indicated decreased blood flow

Term
Eyes: Assessment
Definition

Hx disorders, vision loss, trauma/surgery

difficulty w/ vision

glasses or contact lenses

last vision check

Squinting, head tilting, moving to see object better

 

Abnormalities: cloudiness, lack of red reflex, strabismus, drainage (chronic tearing), redness, yellow sclera

Term
Strabismus
Definition
crossed eyes
Term
What needs to be included in eye Hx?
Definition

past accidents, injuries (especially head), or surgeries

 

Diet deficiencies (vit. A deficiency can cause eye dryness, keratomalacia, and blindness)

 

Environmental exposures: computer overuse (screen), allergen exposure

Term

Ear & Hearing: Assessment

 

Definition

Hx hearing disorders/hearing loss, trauma/surgery

exposure to environmental noise

earaches or infections

vertigo (dizzy)

feeling of fullness in ear

hearing aid use

method of cleaning ears

Term
3 types hearing loss
Definition

Conductive: physical obstruction of sound wave transmission

 

Sensorneural: cochlear defect, 8th cranial nerve, brain abnormality, or from loud noises/music

 

Mixed: profound hearing loss

Term

Nose & Sinus: Assessment

 

Definition

Hx of disorders or trauma/surgery

discharge (color, etc)

frequent &/or severe colds

sinus pain

nasal obstruction

nosebleeds (amt & frequency)

allergies/hay fever

Changes in sense of smell

assess for deformities, tumors, nasal flaring, redness, drainage, bleeding, polyps

Term
Mouth & Throat: Assessment
Definition

Hx disorders or trauma/surgery

pain

frequent sore throats

bleeding gums

toothache

lesions in mouth or on tongue

dysphagia

horseness or voice changes

altered taste

dentures/ prosthetics

last dental checkup

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