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Foundations Test 2
Terms in this set (60)
What does the nurse do in the assessment?
Gather data, record data, inspect, palpate, percuss, auscultate.
What doe the nurse do in the diagnosis?
Identify client's health needs/strengths
What does the nurse do for the planning outcomes?
Decide goals that you want your pt to achieve, formulate realistic goals.
choose interventions to help client achieve stated goals
Action phase when you delegate actions you previously planned. Observe the client's responses as you perform interventions.
Judge whether your actions have successfully treated or prevented the client's health problems. Allows for reassessment and changes to the care plan.
Difference between subjective and objective data?
Subjective: what the patient tells you
Objective: what you observe
Special needs assessment
Complete health history and physical examination. Extensive data, includes subjective and objective data. Ex: Admission into ER.
gathering of baseline data, identifying an individual's learning and support needs.
performed as needed, at any time after the initial database is completed.
EX: rechecking vitals/pt status in hospital stay
collects relevant information pertaining to the current condition of a patient after a change of new symptoms develop.
Collaboration vs coordination
collaboration is working with the doctor or other medical personal to come up with a plan/treatment
coordination is scheduling appointments, pt, rt...
Nursing independent action
does not require an order. Patient teaching/education, encouraging coughing to clear congestion
nursing dependent action
action is dependent on the physicians order, administering meds, taking the patient for exercise.
nursing Collaborative action
working with the PT or doctor to help the patient
actual nursing diagnosis
If the patient has enough signs and symptoms (defining characteristics) to identify the specific nursing diagnosis. The next step is to determine the etiology, and then intervene to treat and/or relieve symptoms.
Potential Nursing Diagnoses
Describes a problem response that is likely to develop if the nurse and patient do not intervene to prevent it
possible nursing diagnosis
exists when your intuition and experience direct you to suspect that a diagnosis is present but don't have enough data.
readiness/wellness nursing diagnosis
When the patient is ready to obtain a healthier lifestyle
Their level of wellness must be effective and the client must want to move to a higher level
used to evaluate the response of the whole person to actual or potential health problems
focuses on the pathology/disease or medical condition
Components of writing a good nursing order?
9/15/19 Offer 100 mL water per hour between 0700-1500. J. Noga, RN.
Diagnostic label, definition, defining characteristics, related factors/risk factors
How do you write a good outcome statement (think SMART)
Specific, Measurable, Attainable, Realistic, Timely.
EX: by end of shift, pt. will walk 15 feet with help of one person and walker.
How do you prioritize/triage your care with multiple patients?
Focus on high priority, whatever is more likely to kill your patient comes first
Things you can delegate to the NAP?
Giving a bath, changing, transporting to radiology or PT, vital signs, taking calls.
Direct nursing care
Cleaning a wound, administering a shot, ambulating with a patient, patient education
Indirect nursing care
nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients.
Entering and reviewing orders, traveling to equipment.
A systematic problem-solving process that guides all nursing actions.
Purpose: provides goal-directed, patient-centered care.
What is the most important thing a nurse can do to prevent falls?
Remove possible risk factors, shag rugs, promote use of nonskid shoes, wear tidy clothing, good lighting.
Why is it important for nurses to be critical thinkers?
It allows for you to think outside the box and consider all options. You can better tailor your care to each patient, considering alternatives, reflecting skeptically, be able to decide what to do.
Twice a day
Out of bed
intake and output
What should you consider when documenting?
Factual; objective, avoid inferences, non-judgmental
Normal physical changes that occur due to aging?
Musculoskeletal (joints, ROM, balance)
Respiratory (pneumonia, decrease elasticity in lungs)
Integumentary (more likely to get skin tears)
Change in hormones
Normal mental changes due to aging?
Normal memory declines, but intelligence does not
cognitive - short term memory declines, coping with loss harder.
Personality - loneliness
What does frail elderly mean?
Must meet ¾ criteria of 1. Low physical activity, 2. Muscle weakness, 3. Overall fatigue, 4. Slow performance
For older adults, what signs and symptoms might you see as a result of polypharmacy and other co-morbidities?
Polypharmacy is the use of multiple medications. It can lead to acute confusion, delirium, and depression. Hard to manage all medications - some may need medication reconciliation.
Depression - isolation, medical problems, side effects from medications.
Ageism - age based discrimination, can cloud nursing assessment/planning and strays away from personalized nursing plan.
Common challenges as people age?
Feeding themselves, cooking meals, driving/getting around, functioning independently, intense exercise
Elder abuse - what should you do?
RN is mandated to report, battering, inappropriate use of drugs/restraints, force-feeding, nonconsensual sexual contact, force feeding, neglect, financial exploitation...
Major safety risks for toddlers?
Choking hazards, falling, getting into poisonous substances
safety risks for small children?
sports, put meds up, stranger danger.
Safety risks for adolescents
Motor vehicle accidents
Guns and weapons
Inhalation and ingestion
02/06/19 1300 Lasix 40 mg PO daily for fluid retention T.O.: Dr. J. Smith/Jodi Noga, RN
02/06/19 1300 Lasix 40 mg PO daily for fluid retention V.O.: Dr. J. Smith/Jodi Noga, RN
charting by exception
documenting only abnormal things.. makes charting easier on nurse.. but a lack of detail could compromise patient safety
communication using body movements, gestures, and facial expressions rather than speech
Communicating with an unconscious patient?
Be careful what is said in person's presence; hearing is the last sense that is lost
Assume the person can hear you and talk in a normal tone of voice
Speak to the person before touching
Keep environmental noises at low level
Communicating with cognitively impaired patients, dementia patients?
Speak clearly, in layman terms, refrain from touching
What can a nurse do/say to help enhance communication? What types of questions are best when assessing a patient?
Ask if they need to reword what they said, used open or closed ended questions.
Communicating with a patient who doesn't speak English?
Keep it simple and short for the translator. Use pictures.
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