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4 types of nursing assessments?
FATE: Focus, Admission, Time-lapse, Emergency
aim & time frame for focus assessment?
done during admission; ongoing process integrated w/ nursing care–few min to a few hrs b/tw assessments
aim & time frame for admission assessment?
initial ID of normal function, functional status, and collection of data concerning actual or potential dysfunction; done w/in specified time frame after admission to hospital, nursing home, ambulatory care center, or home healthcare setting
aim & time frame for time-lapse reassessment?
compare pt. current status vs. baseline obtained previously. detect changes in all fcnl health patterns after extended period of time has passed; several months (3, 6, 9 mo or more) b/tw assessments
aim & time frame of emergency assessment?
ID of life-threatening situation; done anytime physiologic, psychological, or me crisis occurs
3 clinical skills used in assessment?
observation, interviewing, and physical exam
4 techniques used in physical exam?
PAPI: Palpation, Auscultation, Percussion, Inspection
name the 3 components of functional health assessment
PAR: Pattern label, Assessment parameters for each pattern, and Recording of assessment data
Pattern label
name given to a category of assessment data (11 cater. of fcnl health pttrns)
Assessment parameters
specific questions to ask/info to gather based upon each fcnl health pattern
recording of assessment data
recording (using a special form/computer) the assessment parameters and pattern labels
Name 5 purposes of the health assessment
1) Est. a baseline
2) Determine normal function
3) Determine risk of DYSfunction
4) Determine strengths
5) To provide data for diagnosis
Name 2 types of data
subjective and objective
Name 2 sources of data
Primary and Secondary data
Primary data
info from client/patient (i.e: how symptoms effect life, etc)
Secondary data
info from other sources (i.e: family members of lab results)
Name 13 important subjective data to gather
1) Health history
2) Pain Assessment (OLDCARTS)
3) Health perception of pt.
4) Activity/exercise (posture, gait, balance, mobility, <3 fcn) 5) Nutrition/Metabolism 6) Elimination 7) Rest/Sleep 8) Cognition/Perception 9) Self-perception/Self-concept 10) Roles/Relationships (& how rel w/ illness) 11) Coping/Stress tolerance 12) Sexuality/Reproduction 13) Values/Beliefs
Usual order of physical exam?
Palpation, Percussion, Auscultation (unless examining abdomen–then it’s Ausc, Perc, Palp)
Name 5 ways to validate objective data?
1) compare to Normal function
2) use textbooks, journals, research
3) check Consistency for cues
4) Clarify patient’s statements
5) seek Colleagues’ consensus
name the 3 components of functional health assessment (FHP)
pattern label, assessment parameters for each pattern, & recording of assessment data
name the 4 phases of the patient interview (for subjective data)
Preparatory, Introductory, Maintenance, and Concluding phases
body systems model (aka medical model; review of systems)
focuses of pt. major anatomic systems. Nurse collects data about past/present condition of each organ/body system &then thoroughly exams each body system for actual/potential problems
head-to-toe model
nurse examine every body part from head to toe
name the 11 FHP (functional health patterns)
1) Health perception of pt.
2) Activity/exercise (posture, gait, balance, mobility, <3 fcn) 3) Nutrition/Metabolism 4) Elimination 5) Rest/Sleep 6) Cognition/Perception 7) Self-perception/Self-concept 8) Roles/Relationships (& how rel w/ illness) 9) Coping/Stress tolerance 10) Sexuality/Reproduction 11) Values/Beliefs
Functional health pattern model
focuses on client’s normal, altered, and risk for altered function
nursing diagnosis (NANDA)
a clinical judgement about indiv., fam., or community RESPONSES to actual or potential health probs/life processes. Provides the basis for selection of nursing interventions to get to outcomes for which the nurse is accountable.
medical diagnosis
describes a disease
diagnostic reasoning
the process of gathering & clustering data to draw inferences & propose diagnoses
outcome identification
the formulation of pt. goals & measurable outcomes that provide the basis for evaluating nursing diagnoses
clinical reasoning
use of critical thinking to question why pt. has an abnormal finding
those intellectual & affective activities in which indie. engage to explore their experiences in order to lead to new understandings & appreciations.
critical reflectivity
becoming aware if our awareness & critiquing it (where highest learning occurs) (i.e. questioning judgements & considering other ways of thinking ab. situation–alternative explanations)
reflective skepticism
a healthy attitude of doubt toward supposed truths (willingness to consider alt. explanations)
Defining Characteristics (in Nsg Diagnoses)
observable cues/inferences that cluster as manifestations of an actual illness/wellness health state or nursing diagnosis
Related factors (in Nsg Diag.)
describe the conditions, circumstances, or etiology that contrib. to the prob. & will aff what the msg interventions will be. (i.e.: stress incontinence related to High Intraabdominal Pressure vs. stress incontinence related to Overdistention b/tw voidings)
Risk factor (in Nsg diag.)
envir. factors & physiological, psychological, genetic, or chem. elements that increase the vulnerability of a patient to an unhealthful event (tl:dr: a potential problem)
actual nursing diagnosis
describes a human response to a health problem that is being manifested. written as 3 pt. statement: diagnostic label, defining characteristics, and related factors
risk nursing diagnosis
describes a human response to health conditions/life processes, that may develop in a vulnerable patient. written as 2 pt. statement: diagnostic label, and risk factors
wellness nursing diagnosis
describes human responses to levels of wellness in a patient that has readiness for enhancement to a higher state. written as 1 pt statement: diagnostic label
possible nursing diagnosis
made when not enough evidence supports the prob, but the nurse thinks that it is highly probable & wants to collect more info. written as 2 pt statement: diagnostic label, and related factors (unknown)
outcome identification
the formulation of goals & measurable outcomes that provide the basis for evaluating nursing diagnoses
High-priority nursing diagnoses
nsg diagnoses that are potentially life-threatening & req. immediate action. (i.e: Impaired Gas Exchange, Dysreflexia, Self-Directed Risk for Violence)
Medium-priority nursing diagnoses
nsg diagnoses that involve probe that could result in unhealthy consequences like phys/emo impairment, but aren’t likely to threaten life. (i.e.: Fatigue, Stress Incontinence, Dysfunctional Grieving)
Low-priority nursing diagnoses
nsg diagnoses that involve probe that usually can be resolved easily w/ minimal interventions & have little potential to cause significant dysfunction. (i.e: Pain [moderate; after minor surgery])
[patient] outcome
an educated guess, made as a broad statement, about what the pt.’s state will be after the nursing intervention is completed. Directly addresses prob. stated in nursing diagnosis
a description of the parameter for achieving the outcome. (i.e: “Walks” isn’t specific enough–“Ambulates safely w/ 1-person assistance” clarifies the outcome statement)
outcome criteria
specific, measurable, realistic statements of goal attainment. May restate goal, but also present info that’ll guide evaluation phase of the nursing process. (answer who, what actions, under what circumstances, how well, & when.
4th phase of nursing process: development of nsg strategies designed to improve pt. probs
nursing interventions
any treatment, based upon clinical judgement & knowledge, that a nurse performs to enhance pt. outcomes
patient goal
reflects resolution/correction of id’ed prob (>= 1 goal per msg diagnosis)
evaluation [of a nursing intervention]
a written statement that determines the pt.’s progress twd specific outcome criteria
result when a deviation occurs in the [critical] pathway; & alters an expected outcome or discharge date
Cognitive interventions (2 types & brief den)
1) Educational (nurse educated pt. & am on how to do something at home)
2) Supervisory (nurse oversees pt. overall care and makes sure CNA’s are doing their job)
Interpersonal interventions (3 types)
1) Coordinating (act as pt. advocate, make referrals, collar w/ others on hc team)
2) Supportive (use good comm’n & caring to provide comfort & promote healthy resp. to health probs)
3) Psychosocial (focus on resolving me, psych, or social probe–humor, gp therapy, role mod social skills)
Technical Interventions (3 types)
1) Mainenance (help pt. retain certain lvl of health–hygiene, skin care)
2) Surveillance or Monitoring (detect changes from baseline data using all senses)
3) Psychomotor (insert, remov, change, app, admin, cleanse, suction, etc–anything involving a psychomotor action)
the judgement of the effectiveness of nursing care to meet pt. goals based on the pt.’s behavioral responses
standards of care
authoritative statements made by nursing organizations, external review board, or hc institutions that describe the responsibilities of the nursing profession, against which its practitioners are held accountable.
IHI (Institute for Healthcare Improvement)
Independent not-for-profitt organization that has partnered with many healthcare organizations to improve the quality and safety of care delivery while decreasing cost and inefficiency. (i.e: IHI bundles–present EBP)
3 Types of evaluation?
Structure, Process, and Outcome evaluation
Structure evaluation
focus on environment where care is provided (i.e.: avail. of equipment, admin supp., nrse-pt. ratios)
Process evaluation
focus on nurse’s performance (i.e.: info gathered dur. interview & phys exam; validity of nsng diag. sttmts; nurse’s technical competence)
Outcome evaluation
focus on pt. & pt.’s function (extent to which pt. actual outcome reflects desired pt. goal & outcome criteria)
name the 4 possible judgments regarding outcome achievement
1) Goal was completely met
2) Goal was partially met
3) Goal was completely unment
4) New problems or nursing diagnoses have developed
Quality Improvement programs
mechanisms for healthcare organizations to assess and improve care. ensure quality pt. care provided & standards upheld
Who established the Standards of Nursing Practice?
The Joint Commission
external review board that establishes standards for institutions to make sure they function w/in specified guidelines
Define peer review
The evaluation and judgment of a nurse’s perforfmance by other nurses.
ID the 2 types of peer review
1) Nursing Monitor
2) Individual peer review
Nursing monitor (aka nursing audit)
any review completed by a nurse, of a pt.’s care or records to evaluate whether established standards were met. (Members of monitoring committee may review nurse’s documentation of care in health record, or determine pt.’s health status thru observation.)
Individual peer review
Individual nurse’s performance is evaluated & judged by other nurses w/ similar edu & experience
Commission on Collegiate Nursing Education
fosters continued improvement in nursing edu programs. Accreditation is non-gov, peer review process. Ensures quality & integrity of BSN and MSN (but not LPN) Uses NATIONALLY recall. std.’s to eval programs
ANA standards of care? (6)
ADOPIE: Assessment, Diagnosis, Outcome ID, Planning, Implementation, Evaluation
ANA standards of professional performance?
Ethics, Edu, EBP & Research, Qual of Practice, Communication, Leadership, Collab, Professional Practice Eval, Resrc Utilization, Envir health
Which Nsg theorist emphasized the interpersonal interaction b/tw pt. & nurse?
Which nsg theorist focused on helping the pt. gain independence ASAP?
What nsg theorist focused on providing care & assisting pt. to attain self-care?
Nurse is gathering info about a person’s culture & beliefs r/t health; & how these beliefs influence the person. The nurse is eval which FHP?
Health Perception & Health Management
Maslow’s hierarchy of human needs in order (from 1-5)?
Physiologic, Safety, Love, Esteem, Self-Actualization needs
Members in ANA vs NLN?
ANA: Only RNs
NLN: nurse, other HCPs, & lay ppl
3 phases on nurse-pt. relationship?
Orientation, Working, Termination
Positive Regard
viewing the pt. unconditionally; treating them with warmth, caring, interest, and respect uncond.
Problem-focused vs. solution-focused coping? (ch 40)
Which glands are involved in neuroendocrine regulation of stress?
hypothalamus, pituitary, adrenal glands
Differentiate b/tw pulses of 0, 1+, 2+, 3+
0: absent
1+: diminished, thready, easily obliterated pulse
2+: normal, not easily obliterated
3+: increased & full volume pulses
How soon can a nurse with Streptococcus (gp. A) Infection return to work?
24 hrs after start of treatment
How soon can a nurse with diarrhea return to work?
After being symptom free for 3 days
How soon can a nurse with conjunctivitis return to work?
once discharge stops
Differentiate Korotkoff Phase I, II, III, & IV
I: faint, clear tapping sounds that gradually incr in intensity (systolic BP)
II: Swishy
III: Crisper, more intense sounds
IV: muffled blowing sounds
Biot’s breathing pattern
cyclical pattern of shallow breaths alternating w/ apnea
Cheyne-Stokes breathing pattern
cyclical pattern of breaths characterized by periods of increase ARE & depth alternating w/ periods of apnea
RR < 12 (per min)
Kussmaul respirations
increased RR (> 20) & increased depth of respirations
Average resting cardiac output?
5.5 L/min
How to get cardiac output? (math)
Stroke volume x HR (i.e: SV 70 mL & HR 72 bpm= CO 5 L/min)
arterial blood gas ranges for PaO2?
80-100 mm Hg
arterial blood gas range for HCO3?
22-26 mEq/L
arterial blood gas range for PaCO2?
35-45 mm Hg
pH range for arterial blood gas?
max flow rate that can be used for O2 delivery via nasal cannula?
6 L/min

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