Clinical Decision - Final

objective data

information that is seen, heard, felt, or smelled by an observer; signs

Basic research

is research to gain knowledge for knowledge's sake.

The Nursing Process (ADPIE)

A - Assessment (systematic collection and recording of patient data) D - Diagnosis (Using the assessment data to formulate a problem list that will lead to a nursing diagnosis) P - Planning (Prioritize and develop expected patient outcomes) I - Interventions (Steps taken to help patient reach expected outcomes) E - Evaluation (reassess patient and determine if outcomes were met, partially met, or not met at all. Evaluation is an ongoing process that occurs each time you see the patient)

General Systems Theory

- is a method of thinking about complex structures such as an information system or an organization. A simplified description of systems theory holds that any change in one part of a system will be reflected in other parts of the system.

Maslow's Hierarchy of Needs

5) Self-Actualization Needs - Achieve full potential Talents Capabilities Self-aware 4) Esteem Needs - Appreciation, Respect, Accomplishments, Personal Worth 3) Social Needs - Friendships, Romantic relationships, Family, Social groups Community groups, Churches 2) Safety - Financial security, Health and Wellness, Safety against accidents and injury 1) Physiological - Food, water, breathing, homeostasis, water, breath, shelter, clothing, sexual reproduction

preoperational stage

Age 2 to 7 years Begin to think symbolicall Use words and pictures to represent objects Egocentric, struggle to see others' perspectives Language emerges as a major development Learn through pretend play

formal operational stage

Ages 12 and up Begin to think abstractly Teens become moral, philosophical, ethical, social Begin to use deductive logic Think scientifically

concrete operational stage

Ages 7 to 11 years Begin to think logically Using reasoning Less egocentric Understand that their thoughts are unique to them and not everyone feels the same

The nurse observes a UAP performing all of these interventions for a patient with carpel tunnel syndrome. Which action requires the nurse intervene immediately? A) Arranging the patients lunch tray and cutting his meat. B) Providing warm water and assisting the patient with his bath C) Replacing the patient's splint in hyperextension position D) Reminding the patient not to lift heavy objects

C) Replacing the patient's splint in hyperextension position

The client diagnosed with peptic ulcer disease has a blood pressure of 88/42, an apical pulse of 132, and respirations are 28. The nurse writes the nursing diagnosis "altered tissue perfusion related to decreased circulatory volume." Which intervention should the nurse implement first? 1) Notify the laboratory to draw a type & crossmatch. 2)Assess the client's abdomen for tenderness. 3)Insert an 18-gauge catheter and infuse lactated Ringer's. 4)Check the client's pulse oximeter reading.

Answer is 3 Reasoning 1.Notifying the laboratory for a type & crossmatch would be an appropriate intervention since the client is showing signs of hypovolemia, but it is not the first intervention because it would not directly support the client's circulatory volume. 2.The stem of the question has provided enough assessment data to indicate the client's problem of hypovolemia. Further assessment data are not needed. 3.The vital signs indicate hypovolemia, which is a life-threatening emergency that requires the nurse to intervene to support the client's circulatory volume. The nurse can do this by infusing lactated Ringer's. 4.A pulse oximeter reading would not support the client's circulatory volume.

applied research

Applied research directly impacts practice. Most nursing research is applied research.

Dys

Bad, difficult, painful (ie. dysmenorrhea, dyspnea)

sensorimotor stage

Birth to about 2 years of age) Learn through sucking, grasping, looking, and listening Object permanence - objects continue to exist even when they cannot be seen Objects are separate and distinct Begin to attach names and words to objects Interact with their environment Crawling, walking

A nurse receives a change of shift report at 0700 for an assigned caseload of clients. Choose the order in which the clients should be seen. 1) A client who has been receiving a blood transfusion since 0400 2) A client who has an every 4 hour PRN analgesic prescription and who last received pain med at 0430 3) A client who is going for colonoscopy at 1130 and whose informed consent needs to be verified 4) A client who needs rapid onset insulin before the 0800 trays arrive 5) A client who is being discharged today and needs reinforcement of teaching regarding dressing changes A) 3,1,5,2,4 B) 4,2,3,5,1 C) 1,4,2,3,5 D) 2,3,1,4,5

C) 1,4,2,3,5

A few minutes after the nurse has given an intradermal injection to a patient who is undergoing skin testing for allergies, the patient complains about feeling anxious, short of breath, and dizzy. Which of the actions included in the emergency protocol should the nurse take first? A) Start O2 at 4L/min NC B) Obtain IV access with a large bore catheter C) Administer epinephrine (Adrenalin) 0.3 mL SQ D) Give albuterol (Proventil) 2.5 mg via nebulizer

C) Administer epinephrine (Adrenalin) 0.3 mL SQ (The patient is likely going into anaphylactic shock and epinephrine will prevent a cardiac collapse as well as an airway shut down.)

A nurse is preparing to insert a second intravenous catheter (IV) in a client who needs to receive packed red blood cells (PRBC) in addition to his IV antibiotics. Using time management principles, in which order should the nurse perform the following steps? 1) Mentally envision the procedure when collecting supplies for the veni-puncture. 2) Enter the room and perform hand hygiene. 3) Gain informed consent from the client for infusion of PRBC's. 4) Prepare the client and perform the veni-puncture. 5) Follow protocol to obtain blood from the lab. A) 2,1,3,4,5 B) 3,5,1,2,4 C) 1,2,4,5,3 D) 3,1,2,4,5

D) 3,1,2,4,5

After the nurse receives the change-of-shift report at 7:00 AM, which client should be assessed first? A) A 23 year old with a migraine headache who is complaining of severe nausea associated with retching B) A 45 year old who is scheduled for a craniotomy in 30 minutes that needs pre op teaching C) A 59 year old with Parkinson's disease who will need a swallowing assessment before breakfast D) A 63 year old with MS who has an oral temp of 101.8F and flank pain

D) A 63 year old with MS who has an oral temp of 101.8F and flank pain

Priorities

FIRST LEVEL PRIORITY: EMERGENT, LIFE THREATENING, & IMMEDIATE SECOND LEVEL PRIORITY: NEXT IN URGENCY—REQUIRING YOUR PROMPT INTERVENTION TO FORESTALL FURTHER THIRD LEVEL ARE THOSE THAT ARE IMPORTANT TO A PTS HEALTH BUT CAN BE ADDRESSED AFTER MORE URGENT HEALTH PROBLEMS ARE ADDRESSED. COLLABORATIVE PROBLEMS

PICOT model

P - Patient, problem, or population I - Intervention C - Comparison O - Outcome T - Time

Johns Hopkins PET Model

P - Practice Question E - Evidence T - Translation

SBAR

Situation Background Assessment Recommendation

Erikson's Stages of Psychosocial Development

Stage 1: Trust vs. Mistrust - Birth to 1 year Stage 2: Autonomy vs. Shame and Doubt - Early Childhood Stage 3: Initiative vs. Guilt - Preschool Years Stage 4: Industry vs. Inferiority- Ages 5-11 Stage 5: Identity vs. Confusion - Teenage years Stage 6: Intimacy vs. Isolation - Young adults Stage 7: Generativity vs. Stagnation - Adults Stage 8: Integrity vs. Despair - Old age

-ectomy

Surgical removal, cutting out (ie. appendectomy, hemorrhoidectomy, splenectomy)

Adaptation theory

The adjustment of living matter to other living things and to environmental conditions. This occurs on three levels: Internal (self) Social (others) Physical (biochemical reactions)

evidence-based practice

The conviction that all patients deserve to be treated with the most current and best-practice techniques

Civil Rights Act of 1964

Title VI of Civil Rights Act of 1964 states services cannot be denied to people of limited English proficiency.

Trends vs. Isolated findings

Vital Signs - trend Pain Scale - trend Level of Consciousness - isolated finding Glasgow Coma Scale - isolated finding

Nursing Diagnosis

a clinical judgment about actual or potential individual, family or community experiences/responses to health problems/life processes Problem-focused Risk for diagnosis Health Promotion diagnosis

Priority (ABC &D)

a. Airway b. Breathing c. Circulation d. Disability

Delegation

generally involves assignment of the performance of activities or tasks related to patient care to unlicensed assistive personnel while retaining accountability for the outcome. The registered nurse cannot delegate responsibilities related to making nursing judgments.

Theory

gives direction to research

Research

guides practice

-algia

pain, painful condition, suffering (ie. myalgia, mystalgia, neuralgia)

Piaget's stages of cognitive development

sensorimotor, preoperational, concrete operational, formal operational

subjective data

things a person tells you about that you cannot observe through your senses; symptoms