Shared Flashcard Set


Nursing Process Test 2
Nursing Process Test 2

Additional Nursing Flashcards




Planning: Prioritize problems/diagnoses, formulate goals/desired outcomes, select nursing interventions

1. Establish Priorities
- Use Maslow's hierarchy of needs - physiological needs come first
2. Guidelines for writing goals/desired outcomes
- Write in terms of client responses ("The client will")
- Be sure it is realistic for client
- Ensure it is compatible with therapies of other professionals
- Each goal is derived from only one nursing diagnosis
- use observable, measurable terms
- make sure client considers goal important
3. Plan individualized care - specific to each client
Implementing: reassessing the client, determining the nurse's need for assistance, implementing the nursing interventions, supervising the delegated care, documenting nursing activities
1. process of choosing nursing interventions
- not only driven by goal statement, but also etiology of problem
-BASE INTERVENTION ON SCIENTIFIC KNOWLEDGE, CLEARLY UNDERSTAND the intervention, ADAPT ACTIVITIES to the individual client, implement SAFE CARE, provide teaching, support, and comfort, be holistic, respect dignity of client, encourage active participation of client
Evaluating: collecting data related to desired outcomes, comparing data with desired outcomes, relating nursing activities to outcomes, drawing conclusions about problem status, continuing, modifying, or terminating the nursing care plan.
1. Revise plan of care as needed
- "did it work?" - goal was met, goal was partially met, goal was not met
Ensure confidentiality (HIPAA)
1. Objective
2. Date & time
3. Timely
4. Legible/accurate/complete
5. Permanent
6. Terminology/spelling
7. Signed
8. Sequential
9. Legal prudence - best defense against malpractice
Always stay focused on the objective reporting of the patient
1. Up to date info
2. Interactive communication, allow for questions
3. Method for verifying info (repeat back)
4. Minimal interruptions
5. Opportunity to review relevant client data
- change of shift
- telephone (diagnostics)
- telephone order (always read back to physician)
Situation background assessment recommendation
Purpose of Conducting a Health Assessment
Helps the nurse:
1. gather baseline data
2. nursing diagnoses
3. plan the client's care
4. make clinical judgements regarding client's changing health status
5. evaluate the outcomes of nursing care
Physical Assessment
Steps in procedure:
1. planning
2. obtain equipment
3. Prepare Client
-infection control
4. positioning
5. implementation
6. evaluation

1. general survey
2. vital signs
3. head to toe (organize by system)

Physical Assessment:
1. Head
2. Neck
3. Upper Extremities
4. Chest, Abdomen, Genitals
5. Back, Anus, Rectum
6. Lower Extremities

Exam Methods - Integrations with nursing care:
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Olfaction
Variations in Exam Technique: Children
1. Proceed from least invasive or uncomfortable to the most invasive 2. exam of head and neck, heart and lungs, and ROM can be done early 3. ears, mouth, abdomen, and genitals should be left for the end
Variations in Exam Technique: Elderly
1. Be aware of normal physiologic changes
2. Be aware of stiffness of muscles and joints from aging changes or orthopedic surgery
3. Permit ample time for questions and to assume desired positions
4. Adapt techniques to any sensory impairment
5. Plan several assessment times in order not to overtire
Cultural Sensitivity
Arrange for an interpreter if needed

Consider the following:
1. Health beliefs
2. Nutritional habits
3. Alternative Therapies
4. Relationships with family
5. (Dis)Comfort with physical closeness
Pre-test (Diagnostics)
1. teaching: what is it that the client needs to know about the test?
2. client preparation: Prepare the client and gather equipment
3. assessment and data collection to determine teaching strategies
(while test is performed)
Perform or assist with testing
Provide physical and emotional support
Ensure correct labeling, storage and transport of specimen
1. Focus on nursing care, follow-up activities and observation/monitoring
2. Activities = gag reflex, mobility, pass gas
3. Communicate results to appropriate team members (critical or panic values)
Complete Blood Count (CBC)
Basic Screening Test 1. RBC = # of red blood cells/mm(cubed) 2. Hgb = hemoglobin (anemia = PTT test to measure how quickly you clot)
Serum Electrolytes
Screening test for electrolyte and acid-base imbalances
1. Sodium (Na) 135-145 mEq/L
2. Potassium (K) 3.5-5.3 mEq/L
3. Chloride, Calcium, Magnesium, Phosphate
4. Serum Osmolality = solutes in concentration of blood 280-300 mOsm/kg water
5. Increase = fluid deficit (dehydration)
Blood Chemistry
Common tests -
1. BUN & Creatinine - ujsed to evaluate renal function
2. Liver function tests:
- ALT, AST, Albumin, Alkaline phosphatase, Ammonia, Bilirubin, GGT, Prothrombin
- Cardiac Markers: CK (creatine kinase), Myoglobin, Troponin
- BNP (B-type natriuretic peptide) useful in diagnosing and guiding treatment of heart failure
- Lipoprotein profile: Total Cholesterol, HDL (healthy), LDL (lousy), triglycerides
Capillary blood glucose (fingerstick)
-fasting under 120 = :-)

Hemoglobin A1C (Hgb A1C) - glycosylated hemoglobin
- overall cumulative glucose over 3 mo period (normal = 4.0-5.5%) elevated reflects hyperglycemia in diabetics
Specimen Collection (Blood)
1. Provide client comfort, privacy, safety
2. Explain purpose and procedure
3. Use correct procedure or ensure correct procedure is used by staff or client - note if NPO
4. Note relevant info on lab requisition slip
5. assess site for bleeding
6. transport or ensure transportation of specimen to lab promptly
7. Report abnormal lab findings to provider in timely manner
Specimen Collection (Stool)
1. Determine reason for collection.
2. Determine method of obtaining & handling
3. UAP may obtain and collect
4. follow medical aseptic technique
5. know amount to collect (15-30 mL)
6. Instruct client to defecate in clean bedpan, void urine ahead of time, do not place TP in bedpan
7. Assess skin and rectal area for bleeding
8. observe stool for color, consistency, size/shape, odor
9. if Hemoccult test turns blue = blood in stool
Specimen Collection (Urine)
1. Clean voided specimens for routine urinalysis
2. clean-catch or midstream for urine culture
3. timed urine test for endocrine & renal function
4. indwelling catheter specimen
(compare and contrast above)

SPECIFIC GRAVITY - indicator of urine concentration (1.010-1.025)
URINARY pH - acid/base status (6)
Glucose, ketones, protein, occult blood = none
Osmolality - measure of solute concentration (500-800 mOsm/kg)
Specimen Collection (Sputum)
1. For culture & sensitivity to identify specific microorganism and drug sensitivities 2. for cytology to identify origin, structure, function and pathology of cells 3. for acid-fast bacillus (AFB) to test for TB 4. To assess effectiveness of therapy Morning is the best time to collect sputum (not spit)
Common Diagnostic Measures (GI)
- Anoscopy - viewing of anal canal
- proctoscopy - viewing of rectum
- proctosigmoidoscopy - viewing of rectum and sigmoid colon
- colonoscopy - viewing of large intestine

upper GI or lower GI
- informed consent
-bowel prep (GoLightly) can be very uncomfortable
- NPO *upper GI*, clear liquids *lower GI*
- gag reflex must return or must pass gas

-all direct/invasive procedures for any malfunction to GI tract.
Common Diagnostic Measures (Urinary)
-X-rays of kidney/ureters/bladder (KUB)
-Intravenous pyelography (IVP) and retrograde pyelography - radiographic studies using contrast medium (check patient allergies to iodine/shellfish)
- Renal ultrasonography - non invasive, uses sound waves to visualize kidneys
-cystoscopy - bladder and urethra directly visualized using cystoscope inserted thru urethra (informed consent required)
Common Diagnostic Measures (Cardio Pulmonary)
Electrocardiography (ECG) - graphic recording of heart's electrical activity (ni = noninvasive) stress electrocardiography - assess client's response to increase cardiac workload (ni) angiography - radiopaque dye injected to view blood flow in heart (i) informed consent required echocardiogram - ultrasound to visualize structures of heart (ni) lung scan v/q - records emissions from radioisotopes that indicate how well gas and blood travel thru lungs (i) radioisotope injected by IV (Ventilation/Perfusion) Laryngoscopy and bronchoscopy - sterile procedures to collect biopsies (i) informed consent required, gag reflex must return, NPO, use of sedation
Other common diagnostic measures (visualization)
Computed Tomography (CT) - noninvasive unless contrast medium used, shows differences in density of tissues, 3D image

Magnetic Resonance Imaging (MRI) - noninvasive unless contrast medium used, magnetic field, no metal devices in client, no exposure to radiation, better contrast than CT.

Nuclear Imaging - for bone density, involve use of radioactive isotopes targeted to specific organ, "hot"
spots vs. "cold" spots
- PET Positron Emitting Tomography - non-invasive (inhalation of radioisotope), allows study of organ function, evaluate blood flow and tumor growth, like MRI and CT combined
Other Common Diagnostic Measures (aspiration/biopsy)
Lumbar Puncture - aspiration of spinal fluid (CSF) thru needle inserted between L4-L5

Abdominal paracentesis - aspiration of fluid specimen for lab study, relieve pressure on abdominal organs

Thoracentesis - aspiration of fluid that can accumulate due to injury, infection, remove air or fluid to ease breathing, introduce chemotherapeutic drugs intrapleurally, use sitting position

Bone Marrow Biopsy: removal for lab study to detect specific diseases of blood, bones used = sternum, iliac crest (PSIS)

Liver biopsy - generally performed at bedside, apply pressure and position client on side of puncture
Critical Thinking
Disciplined, self-directed thinking that displays mastery of intellectual skills and abilities

-Stop and think about what you see. Take nothing for granted.

- Allows a nurse to be a safe, competent, skillful practitioner

Skills Include - ability for critical analysis, perform inductive and deductive reasoning, make valid inferences differentiate facts from opinions, evaluate credibility of sources, clarify concepts, and recognize assumptions
Nursing Process
A systematic, rational method of planning and providing individualized nursing care for individual families, communities, and groups

1. Assess
2. Diagnose
3. Plan
4. Implement
5. Evaluate
Assessing: Collect data, organize data, validate data, document

1. Differentiate types of data
- subjective - symptoms or covert data (itching, pain, feelings)
- objective - signs or overt data (measurable - can be seen, heard, felt or smelled)

2. Methods of data collection
- Observe - gather data by using senses: notice data and interpret data
- Interview - planned communication with purpo9se i.e. health history
- physical assessment - uses observation to detect health problems
- diagnostic and lab reports (reading)

3. Aspects of an interview
-Influenced by time, place, seating, distance, language
- 3 stages: orientation/intro, body/development, closing
Diagnosing: Analyze data, identify health problems, risks, and strengths, formulate diagnostic statements
1. components of nursing diagnosis (NANDA)
- problem and definition -> activity intolerance: insufficient energy for ADLs
- related factors/etiology -> bed rest
- defining characteristics -> verbal report of fatigue

What's the problem, what's causing it to occur, what did we assess?

2. Types of nursing diagnoses
- Actual - client problem that is present at the time of assessment
- Health Promotion - relates to client's readiness to implement behaviors to improve
- Risk - Clinical judgement that problem risk factors are present
- Wellness - describe human responses to levels of wellness
Stages of Health Behavior Change
Precontemplation - person doesn't think about changing his behavior in the next six months

contemplation - person acknowledges having problem, seriously considers changing behavior, gathers info, verbalizes plans to change

preparation - person intends to take action in the immediate future

action - person actively implements behavioral and cognitive strategies to adopt new behaviors

maintenance - person strives to prevent relapse by integrating new behaviors into lifestyle

termination - ultimate goal where problem is no longer a temptation or threat
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