FON Exam #2

What does a pt centered goal represent

Predicted resolution of a diagnosis or problem, evidence of progress toward resolution, progress toward improved health status, or continued maintenance of good health or function

Thinking independently

Read the nursing literature, especially when there are different views on the same subject. Talk with other nurses and share ideas about nursing interventions.

Domain 4

Safety, care that supports protection against harm

Written care plans organize information exchanged by whom

Nurses in hand-off reports

pneumocentesis

surgical puncture of a lung to drain fluid that has accumulated

thoracentesis

surgical puncture to remove fluid from the chest

What should the reports focus on

Nursing care, treatments, and expected outcomes documented in care plans

gastrectomy

surgical removal of part or all of the stomach

splenectomy

surgical removal of the spleen

lymphedema

swelling due to an abnormal accumulation of lymph fluid within the tissues

Bones of the forearm

radius and ulna

lobectomy

removal of a lobe of a lung

shoulder blade

scapula

Where was Neuman a professor at?

UCLA

Aorta

the artery by which blood leaves the heart through

Bones of the lower leg

tibia and fibula

clinical practice guideline

systematically developed set of statements that helps nurses, physicians, and other healthcare providers make decisions about appropriate healthcare for specific clinical situations

Critical pathways

Patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially

What are specific statements also relevant to

Patient needs, specific, singular, observable, measurable, and time limited, mutual, realistic

Domains

Use broad terms to organize more specific classes and interventions

Basic critical thinking

-thinking is concrete and based on a set of rules and principles -you likely follow the procedure step by step without adjusting it to meet the patient's needs -you do not have enough experience to individualize the procedure -tend to think that there is only one right answer for each problem

Reflection

-turning over a subject in the mind and thinking about it seriously -involves purposeful thinking back or recalling a situation to discover its purpose and meaning -playing back a situation in your mind and taking time to honestly review everything about it

Commitment critical thinking

-you anticipate when to make choices without assistance from others and accept accountability for decisions made -you choose an action or belief that is based on the available alternatives and support it -you consider the results of the decision and determine if it is appropriate

The consultant is not there to what

Take over the problem, but to help you solve it

4 stages of digestive system

ingestion, digestion, absorption, elimination

Long term goal

An objective behavior or response expected within days, weeks, or months

Short term goal

An objective behavior or response expected within hours to a week

Lines of Resistance

Defenses activated by the client system when internal or external environment factors stress the client system. A protective mechanism that attempts to stabilize the client system and foster a return to the usual wellness

Questions to ask yourself after identifying a nursing diagnosis for a pt

1. What is the best approach to resolve each problem? 2. What do I plan to achieve?

Classes

30 classes which offer useful clinical categories to reference when selecting interventions

Neuman is a fellow of what organization?

American Academy of Nursing

Priority setting begins where

At a holistic level when you identify and prioritize a patient's main diagnoses or problems

Pericardium

Double-layered membrane surrounding the heart.

Measuring outcomes helps what

Gauge the quality of health care

Intrapersonal stressors

Happen within the client system boundary

Types of stressors:

Intrapersonal, interpersonal, & extrapersonal

NIC

Nursing interventions classification

Example of goal

Pt will have decrease in pain by 2/16/17 @ 17:00

What do expected outcomes determine

When a specific, patient-centered goal has been met

Responsibility and authority

Ask for help if you are uncertain about how to perform a nursing skill. Refer to a policy and procedure manual to review steps of a skill. Report any problems immediately. Follow standards of practice in your care.

Diagnostic reasoning

-analytical process for determining a patient's health problems -necessary before you decide on solutions and implement actions -assign meaning to the behaviors and physical signs and symptoms presented by a patient

Complex critical thinking

-begin to separate themselves from experts -you analyze the clinical situation and examine choices more independently -know that each solution has benefits and risks that you weigh before making a final decision -thinking becomes more creative and innovative -take a variety of approaches to the same therapy

Experience

-COMPONENT of critical thinking -clinical learning experiences are important for acquiring clinical decision-making skills -you learn from observing, sensing, talking with patients and families, and reflecting actively on all experiences -with experience, you understand clinical experiences, recognize cues of health patterns, and interpret those cues

Attitudes

-COMPONENT of critical thinking -defines the features of a critical thinker and how they approach a problem

Nursing process competency

-COMPONENT of critical thinking five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating -to diagnose and treat human responses

Specific knowledge base

-COMPONENT of critical thinking -prepares you to better anticipate and identify patient's problems by understanding their origin and nature -knowledge varies according to education and experience -knowledge base is continually changing as science progresses

10 subtopics of physiological

-Fluid/Electrolyte status -Oxygenation -Elimination -Tissue Integrity -Nutritional Status -Sensory-Perpetual status -sleep/rest -activity/mobility status -safety/ comfort status -sexuality assessment

Scientific method

-a methodical way to solve problems using reasoning -systematic ordered approach to gather data and solve problems used by healthcare professionals

Decision making

-a product of critical thinking that focuses on problem resolution -following a set of criteria helps make a thorough and thoughtful decision

Reflective journaling

-a tool for developing critical thought and reflection by clarifying concepts -reflective writing gives you the chance to define and express clinical experiences in your own words

Intellectual standards

-principle for rational thought -applied during all steps of the nursing process

Steps of the scientific method:

1.) Identify the problem 2.) Collect data 3.) Formulate a question or hypothesis 4.) Test the question or hypothesis 5.) Evaluate the results of the test

When stressors penetrate flexible and normal lines of defense and lines of resistance, what two things happen?

Energy depletion and system instability

Expected outcomes

Objective criterion for goal achievement A specific measurable change in a patient's status that you expect in response to nursing care

Discipline

Be thorough in whatever you do. Use known scientific and practice-based criteria for activities such as assessment and evaluation. Take time to be thorough and manage your time effectively.

How does one avoid bias during consultation

By not overloading consultants with subjective and emotional conclusions about the patient problem

Main purpose of critical pathways

Deliver timely care at each phase of the care process for a specific type of patient

What else is a part of priority setting

Ethical care

Professional standards

Ethical criteria for nursing judgments, evidence-based criteria used for evaluation, and criteria for professional responsibility -requires you to use critical thinking and promote the highest level of quality nursing care

Domain 6

Health system, care that supports effective use of the health care delivery system

Interventions

542 treatment interventions based on clinical knowledge and judgement that a nurse performs to enhance patient outcomes

Classification of priorities

High --> Life threatening/emergent Intermediate Low --> Affect patient's well being

counseling

A direct care method that helps a patient use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships.

Do not do what with consultants

INFLUENCE

4 According to Nursing Diagnosis Association-International (NANDA-I), health promotion nursing diagnosis involves a clinical judgment concerning motivation and desire to increase well-being and actualize human health potential. The education imparted by the group is targeted at motivating and increasing the well-being of the community. A medical diagnosis is a general term that involves the identification of a condition based on a specific evaluation of physical signs and symptoms. It encompasses all kind of diagnosis. NANDA-I defines risk nursing diagnoses as a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions. Problem-focused nursing diagnoses describe a clinical judgment concerning an undesirable human response to a health condition that exists in an individual or a community.

A group of nurses is organizing an educational session to teach the population of a particular community about the roots of cardiovascular disease and its impact on the human body. Which type of nursing diagnosis is being followed in this scenario? 1 Medical diagnosis 2 Risk nursing diagnosis 3 Problem-focused nursing diagnosis 4 Health promotion nursing diagnosis

External environment

INTERpersonal and extra personal within the system - outside

Internal environment

INTRApersonal within the system - inside

Nursing-sensitive patient outcome

A measurable patient, family, or community state, behavior, or perception largely influenced by and sensitive to nursing intervention

D A nursing diagnosis in a PES format includes the diagnostic label, related factor, and the defining characteristics by which the diagnosis is evidenced. The second nursing diagnosis is the correct format in the two-part format for writing a diagnosis. The first diagnosis has no related factor. The third diagnosis is an error, using a goal as a related factor.

A nurse assesses a young woman who works part time but also cares for her mother at home. The nurse reviews clusters of data that include the patient's report of frequent awakenings at night, reduced ability to think clearly at work, and a sense of not feeling well rested. Which of the following diagnoses is in the correct PES format? A. Disturbed Sleep Pattern evidenced by frequent awakening B. Disturbed Sleep Pattern related to family caregiving responsibilities C. Disturbed Sleep Pattern related to need to improve sleep habits D. Disturbed Sleep Pattern related to caregiving responsibilities as evidenced by frequent awakening and not feeling rested

C In this scenario the related factor is the mother's deficient knowledge. A related factor is a condition, historical factor, or etiology that gives a context for the defining characteristics, in this case the infant crying, inability to latch on to breast, and absent weight gain.

A nurse in a mother-baby clinic learns that a 16-year-old has given birth to her first child and has not been to a well-baby class yet. The nurse's assessment reveals that the infant cries when breastfeeding and has difficulty latching on to the nipple. The infant has not gained weight over the last 2 weeks. The nurse identifies the patient's nursing diagnosis as Ineffective Breastfeeding. Which of the following is the best "related to" factor? A. Infant crying at breast B. Infant unable to latch on to breast correctly C. Mother's deficient knowledge D. Lack of infant weight gain

D A data cluster is a set of cues (i.e., the signs or symptoms gathered during assessment).

A nurse interviewed and conducted a physical examination of a patient. Among the assessment data the nurse gathered were an increased respiratory rate, the patient reporting difficulty breathing while lying flat, and pursed-lip breathing. This data set is an example of: A. Collaborative data set. B. Diagnostic label. C. Related factors. D. Data cluster.

2, 3, 5, 1, 4 After the complete assessment of the patient's health status, the nurse should interpret and analyze the meaning of the data. The next step involves the nurse classifying the signs and symptoms of the patient's condition. Then, the nurse should look for defining characteristics and related factors. After this step is completed, the nurse must identify the patient's needs. The final step of the nursing diagnostic process involves formulating the nursing diagnoses and the collaborative symptoms present in the patient.

A nurse is assessing the health status of a patient. There are no additional data needed for the assessment procedure. In which order should the nurse follow the nursing diagnostic process after this stage? 1. The nurse should identify the patient needs. 2. The nurse should interpret and analyze the meaning of the data. 3. The nurse should classify signs and symptoms. 4. The nurse should formulate the nursing diagnoses and collaborative symptoms. 5. The nurse should look for defining characteristics and related factors.

A This is the correct steps for making a nursing diagnosis.

A nurse is assigned to a new patient admitted to the nursing unit following admission through the emergency department. The nurse collects a nursing history and interviews the patient. What are the steps for making a nursing diagnosis in the correct order, beginning with the first step? 1. Considers context of patient's health problem and selects a related factor 2. Reviews assessment data, noting objective and subjective clinical information 3. Clusters clinical cues that form a pattern 4. Chooses diagnostic label A. 2, 3, 4, 1 B. 3, 2, 4, 1 C. 2, 3, 1, 4 D. 1, 4, 3, 2

D Intestinal colitis is a medical diagnosis. The related factor in a nursing diagnostic statement is always within the domain of nursing practice and a condition that responds to nursing interventions. Nursing interventions do not change a medical diagnosis.

A nurse is reviewing a patient's list of nursing diagnoses in the medical record. The most recent nursing diagnosis is Diarrhea related to intestinal colitis. For which of the following reasons is this an incorrectly stated diagnostic statement? A. Identifying the clinical sign instead of an etiology B. Identifying a diagnosis on the basis of prejudicial judgment C. Identifying the diagnostic study rather than a problem caused by the diagnostic study D. Identifying the medical diagnosis instead of the patient's response to the diagnosis.

A, C, E Asking "How is your diabetic diet affecting you and your family?" "What worries you the most about having diabetes?" and "What do you believe will help you control your blood sugar?" are open-ended and allow the patient to share his values and health practices. The statements "You seem to not want to follow health guidelines. Can you explain why?" and "What do you expect from us when you do not take your insulin as instructed?" both show the nurse's bias.

A nurse is getting ready to assess a patient in a neighborhood community clinic. He was newly diagnosed with diabetes just a month ago. He has other health problems and a history of not being able to manage his health. Which of the following questions reflects the nurse's cultural competence in making an accurate diagnosis? (Select all that apply.) A. How is your diabetic diet affecting you and your family? B. You seem to not want to follow health guidelines. Can you explain why? C. What worries you the most about having diabetes? D. What do you expect from us when you do not take your insulin as instructed? E. What do you believe will help you control your blood sugar?

3, 4 NANDA-I diagnoses have a broad literature base, and many are evidence-based. NANDA-I diagnoses are continually refined by the professional nurses, not primary health care providers. NANDA-I diagnoses have a broad literature base for the nurse's reference. NANDA-I classifications are considered one of the most comprehensive of all the nursing classifications. NANDA-I diagnoses emphasize providing accurate documentation of health problems.

A nurse is teaching a group of nursing students about the usage of NANDA-I terminologies in the medical record entry. Which statements by the student indicates the need for further education? Select all that apply. 1 " NANDA-I diagnoses have a broad literature base." 2 "NANDA-I classifications are most comprehensive." 3 "NANDA-I diagnoses do not comprise evidence-based diagnoses." 4 "NANDA-I diagnoses emphasize precise documentation of health problems." 5 "NANDA-I diagnoses are refined by the primary health care provider on a regular basis."

A, C This is an example of an error in interpretation and data collection. When making a diagnosis, the nurse must interpret data that he or she has collected by identifying and organizing relevant assessment patterns to support the presence of patient problems. In the case of the two diagnoses in this question, there can be conflicting cues. The nurse must obtain more information and recognize the cues that point to the correct diagnosis.

A nurse reviews data gathered regarding a patient's ability to cope with loss. The nurse compares the defining characteristics for Ineffective Coping with those for Readiness for Enhanced Coping and selects Ineffective Coping as the correct diagnosis. This is an example of the nurse avoiding an error in: (Select all that apply.) A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. E. Goal setting.

B The more appropriate nursing diagnosis for this patient would be Risk for Impaired Skin Integrity because the patient's skin is clean and intact. A risk nursing diagnosis is appropriate because the patient has two risk factors, radiation and secretions on the skin.

A nursing student is working with a faculty member to identify a nursing diagnosis for an assigned patient. The student has assessed that the patient is undergoing radiation treatment and has had liquid stool and the skin is clean and intact; therefore she selects the nursing diagnosis Impaired Skin Integrity. The faculty member explains that the student has made a diagnostic error for which of the following reasons? A. Incorrect clustering B. Wrong diagnostic label C. Condition is a collaborative problem. D. Premature closure of clusters

C It is likely the charge nurse suspects that the student has not collected enough cues to support the diagnosis. A change in blood pressure and mental status changes are significant findings that can be attributed to fluid volume excess and other diagnoses. The recommendation of the symptom cluster by the registered nurse would allow the student to have sufficient data to confirm a deficient fluid volume.

A nursing student reports to a lead charge nurse that his assigned patient seems to be less alert and his blood pressure is lower, dropping from 140/80 to 110/60. The nursing student states, "I believe this is a nursing diagnosis of Deficient Fluid Volume." The lead charge nurse immediately goes to the patient's room with the student to assess the patient's orientation, heart rate, skin turgor, and urine output for last 8 hours. The lead charge nurse suspects that the student has made which type of diagnostic error? A. Insufficient cluster of cues B. Disorganization C. Insufficient number of cues D. Evidence that another diagnosis is more likely

3, 4, 5 The nurse should identify treatable etiology or risk factors, the problems caused by the treatment, and the patient's response in order to reduce errors in the diagnostic statement. Identifying a medical diagnosis does not reduce errors in the diagnostic statement. Similarly, identifying clinical signs and symptoms helps focus treatment but does not reduce diagnostic errors.

A patient diagnosed with pancreatitis complains of pain in the abdomen. Following an initial interview and the assessment, the nurse prepares a nursing care plan. Which guidelines should the nurse follow to reduce errors in the diagnostic statement? Select all that apply. 1 Identify medical diagnoses. 2 Identify clinical signs and symptoms. 3 Identify treatable etiology or risk factors. 4 Identify the problems caused by the treatment. 5 Identify the patient's response.

1 A related factor is the reason for the nursing diagnosis. A change in the related factor tends to bring about a change in the nursing diagnosis and the patient's condition. The patient has acute pain due to inflammation of the pancreas. The related factor is inflammation of the pancreas. The acute pain diagnosis would change if there were a change in the status of the related factor. Fever, distention of the abdomen, and vomiting are not the reasons for the patient's pain.

A patient diagnosed with pancreatitis complains of pain in the abdomen. The patient has vomited three times, and has a temperature of 101° F. Following an initial interview and assessment, the nurse prepares a nursing care plan. The nurse formulates a diagnosis of acute pain. What could be the related factor for this diagnostic label? 1 Inflammation of the pancreas 2 Fever 3 Distention of the abdomen 4 Vomiting

1, 3, 4 Giving satisfactory answers to the patient's questions should make the patient less anxious. Providing detailed instructions about the recovery process and the surgical procedure helps the patient become familiar with the operation and reduces anxiety. Performing range-of-motion exercises is helpful for impaired physical mobility but probably will not decrease anxiety. Providing instructions about discharge planning is unlikely to reduce the patient's anxiety.

A patient is anxious about an operation scheduled for the next day. The nurse identifies that the patient is anxious. Which interventions does the nurse use to decrease the patient's anxiety related to surgery? Select all that apply. 1 Provide satisfactory answers to the patient's questions. 2 Instruct the patient to perform range-of-motion exercises. 3 Provide detailed instructions about the recovery process. 4 Provide detailed instructions about the surgical procedure. 5 Provide detailed instructions about discharge planning.

2 Urinary stress incontinence is an actual diagnosis. An actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A nursing risk diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A nursing health promotion diagnosis is a clinical judgment of a person's, family's, or community's motivations, desires, and readiness to increase well-being. A chronic diagnosis is not a type of nursing diagnosis.

A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis? 1 Risk diagnosis 2 Actual diagnosis 3 Chronic diagnosis 4 Health promotion diagnosis

4 According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the nurse should maintain confidentiality about the health information of the patient. Therefore, the nurse should politely tell the caregiver that accessing the patient's medical records is not in accordance with the law. There is no need to report to the primary healthcare provider because it is not an emergency situation. Ignoring the caregiver's words is not professional. The nurse should not give access to the patient's medical records unless an informed consent is obtained from the patient.

A patient's caregiver asks the nurse, "Can I view the patient's medical records?" What should the nurse do in this situation? 1 Report to the primary healthcare provider immediately, by placing a call to the office. 2 Ignore the caregiver's request and carry on with the work; if it comes up again, address it. 3 Respect the caregiver's wish and show the patient's medical records to adequately provide care. 4 Politely tell the caregiver that disclosing the medical records to others is not in accordance with the law.

Patient centered care requires you to know what

A patient's preferences, values, and expressed needs

Cartilage

A specialized type of dense connective tissue can withstand pressure and tensions; attached to the ends of bones and forming parts of structures, such as the nasal septum and the framework of the ear.

Patient centered goal

A specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function

bile

A substance produced by the liver that breaks up fat particles.

What is important when administering medications or implementing procedures

Ability to recognize incorrect therapies

2, 3, 5 Collecting, clustering, and interpreting data are common sources of errors in the nursing diagnostic process, according to NANDA-I. In the data collection process, errors sometimes occur due to a lack of knowledge or skills, inaccurate data, missing data, and disorganization. In clustering, errors may occur due to an insufficient cluster of cues, premature or early closure, and incorrect clustering. In the interpreting process, errors may occur due to inaccurate interpretation of cues, failure to consider conflicting cues, and the use of unreliable or invalid cues. Implementation and evaluation are not included in the nursing diagnostic process.

According to the NANDA International, what are the categories of sources of error that may occur in the nursing diagnostic process? Select all that apply. 1 Implementing 2 Collecting 3 Clustering 4 Evaluating 5 Interpreting

Primary prevention

Actions taken BEFORE there is any disease process

Correctly written nursing interventions include what

Actions, frequency, quantity, method, person to perform them

NOC suggested outcomes (individuals, families, communities)

Activity tolerance Aspiration PNA GI function Pain control

Central core of Neuman model:

Consists of basic survival factors (normal temperature range, genetic structure, response pattern, organ strength/weakness, ego structure). Basic components, energy resources, wholistic interactions.

Curiosity

Always ask why. A clinical sign or symptom often indicates a variety of problems. Explore and learn more about the patient so as to make appropriate clinical judgments.

What does establishing priorities help nurses do

Anticipate and sequence nursing interventions for patients with multiple diagnoses/problems

When can consultation occur

At any step of the nursing process

How to start a consult

Begin with your understanding of the pt's problem

Domain 3

Behavioral, care that supports psychosocial functioning and facilitates lifestyle changes

Who developed the Neuman Nursing Theory?

Betty Neuman

Goal

Broad statement that describes the desired change in a patient's condition or behavior Aim, intent, end

Six factors to consider when selecting interventions

Characteristics of nursing diagnosis Goals and expected outcomes Evidence base for interventions Feasibility of the interventions Acceptability of the patient Nurse's competency

Interdisciplinary care plan

Contributions from all disciplines involved in pt care

Normal Line of Defense

Clients normal or usual wellness level. Represents what the client has become/evolved over time. Defines stability and integrity of client system. Standard against determining variance from wellness. Is maintained, increases/decreases as client responds to stressors.

NOC provides what

Common nursing language for continuity of care and measuring the success of nursing interventions

Change of shift report

Communicates information from offgoing to ongoing pt care personnel = "Nurse handoff"

Domain 7

Community, care that supports the health of the community

Health care provider initiated

Dependent --> Require order from a physician or other health care professional

The nurse in the Neuman model:

Determines clients perspective BEFORE analysis and synthesis of data. Uses communication skills to validate and clarify the client's perspective.

What are the 5 personal variables identified in the Betty Neuman Model

Developmental Spiritual Psychosocial Sociocultural Physiological

Risk taking

If your knowledge causes you to question a health care provider's order, do so. Be willing to recommend alternative approaches to nursing care when colleagues are having little success with patients.

Neuman client system is conceptualized as:

Individual, family, group, community, sometimes entire societies/global, person = client system

The plan of care should be what

Individualized

A plan of care is what two things

Dynamic and changes as the patient's

What type of practice did Neuman work in?

Family therapy

Domain 5

Family, care that supports the family

Consultation can be __________ or ___________

Formal or informal

Flexible Line of Defense

Forms the outer boundary of the defined client system. Acts as a protective buffer system for clients normal line of defense or wellness state. Prevents stressor invasion. Lines expand/contract depending on protection available to client at any point in time.

Bedside rounds do what for patients?

Give the pts opportunity to ask questions and confirm information

Adverse Reactions

Harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention.

When ethical issues make priorities less clear, what is it important to do

Have an open discussion with a a patient, family, and other health care providers

Neuman model is an open system.

Have boundaries, interact with the environment and each other, dynamic, becomes more complex, input/throughput/output

3, 4 The nurse assessing the edema in a patient's lower leg who is unsure how to assess the severity of edema fails to validate her assessment findings of edema, either by using a scale to measure the severity or by asking a colleague to validate her findings. The nurse who identifies a diagnosis based on a single defining characteristic prematurely closes clustering, which can lead to an inaccurate diagnosis. The nurse who listens to lung sounds after a patient reports difficulty breathing validates findings to make an accurate diagnosis. The nurse who considers conflicting cues in deciding which diagnostic label to choose interprets cue clusters to make an accurate diagnosis. In all cases the related factor or risk factor is a condition for which the nurse can implement preventative measures, not a medical diagnosis.

In the examples given, which nurses are making nursing diagnostic errors? Select all that apply. 1 The nurse who listens to lung sounds after a patient reports difficulty breathing 2 The nurse who considers conflicting cues in deciding which diagnostic label to choose 3 The nurse who is assessing the edema in a patient's lower leg and is unsure how to assess the severity of edema 4 The nurse who identifies a diagnosis based on a single defining characteristic 5 The nurse who identifies a risk-for diagnosis related to a medical diagnosis

1, 2, 3, 5 A nurse who listens to lungs for the first time and is not sure if abnormal lung sounds are present is displaying a lack of skill, an error in collecting data. After reviewing objective data, a nurse who selects a diagnosis of fear before asking the patient to discuss her feelings is using an insufficient number of cues, which is an error in interpretation. A nurse who uses an incorrect diagnostic label is not accurately identifying the problem, which is a labeling error. A nurse who prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern is an example of incorrect clustering, a clustering error.

In the given examples, which nurses are making nursing diagnostic errors? Select all that apply. 1 A nurse listens to lungs for the first time and is not sure if abnormal lung sounds are present. 2 After reviewing objective data, a nurse selects a diagnosis of fear before asking the patient to discuss her feelings. 3 A nurse uses an incorrect diagnostic label. 4 A nurse considers a patient's cultural background when reviewing cues. 5 A nurse prepares to complete a decision on diagnosis and realizes that clinical criteria are grouped incorrectly to form a pattern.

A, D, E When the nurse observes the patient wincing and holding his left side but does not gather additional assessment data, he or she makes a data collection error by omitting important data (i.e., pain severity). A nursing diagnosis cannot be made on basis of a single defining characteristic, as seen when the nurse identifies a diagnosis on the basis of a patient reporting difficulty sleeping. A nursing diagnosis needs to be related to a patient's response, not a medical diagnosis such as pneumonia. The nurse who measures joint range of motion after the patient reports pain is correctly validating findings. Considering conflicting clues ensures that the nurse does not make an interpretation error.

In which of the following examples are nurses making diagnostic errors? (Select all that apply.) A. The nurse who observes a patient wincing and holding his left side and gathers no additional assessment data B. The nurse who measures joint range of motion after the patient reports pain in the left elbow C. The nurse who considers conflicting cues in deciding which diagnostic label to choose D. The nurse who identifies a diagnosis on the basis of a patient reporting difficulty sleeping E. The nurse who makes a diagnosis of Ineffective Airway Clearance related to pneumonia.

What does the nursing care plan reduce the risk for

Incomplete, incorrect, or inaccurate care Changes as the patient's problems and status change

Mutual factors

Increase patients motivation and cooperation

Nurse initiated interventions

Independent --> Actions that a nurse initiates DO not require order from a health care professional

Collaborative intervention

Interdependent --> Require combined knowledge, skill, and expertise of multiple health care professionals

System stability can be affected by what?

Internal and external environment factors (stressors)

Three distinct environments influence Neuman system:

Internal, External, Created (environment)

Nurses need to

Know the scientific rationale for the intervention Possess the necessary psychomotor and interpersonal skills Be able to function within a setting to use health care resources effectively

Consultation will increase what

Knowledge and help you learn new skills and how to obtain additional resources

Confidence

Learn how to introduce yourself to a patient; speak with conviction when you begin a treatment or procedure. Do not lead a patient to think that you are unable to perform care safely. Always be well prepared before performing a nursing activity. Encourage a patient to ask questions.

Fairness

Listen to both sides in any discussion

Expected outcome

Measurable criteria to evaluate goal achievement Several outcomes must be met to achieve a goal

Planning involves consultation with who

Members of the health care team

pleura

Membrane surrounding the lungs

Diaphragm

Muscular wall separating the abdominal and thoracic cavities.

What do patients have to do to participate in goal setting

Need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making

Who is legally responsible for carrying out an incorrect order

Nurse

Interpersonal stressors

Occur in the external environment but proximal to the client system boundary

Where is Neuman from?

Ohio

4 A nursing diagnosis focuses on a patient's potential response to a health problem. A nursing diagnosis provides a basis for selecting, planning, and implementing interventions. Diseases, complications, and physiological events are not the focus when formulating the nursing diagnosis. These components are part of a medical diagnosis.

On what should the nurse focus when formulating a nursing diagnosis? 1 Disease 2 Complication 3 Physiological event 4 Potential response to a health problem

Critical thinking involves:

Open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant

Optimal system stability

Optimal wellness is the greater possible degree of system stability at a given point in time.

Definition of priorities

Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions

Nurse-sensitive patient outcomes

Outcomes that are within the scope of nursing practice; consequences or effects of nursing interventions that result in changes in the patient's symptoms, functional status, safety, psychological distress, or costs.

Interacting system variables

Physiological, psychological, socio-culture, developmental, spiritual

Level 1 Domain

Physiological: Basic, care that supports physical functioning

Domain 2

Physiological: Complex, care that approach homeostatic regulation

Stressors can be:

Positive or negative, depending on clients perspective

Tertiary prevention

Post acute care, retraining and prevention of additional squeals or concerns

After identifying a patient's nursing diagnoses and collaborative problems, the nurse does what

Prioritizes the diagnoses, sets patient-centered goals and expected outcomes, and chooses nursing interventions appropriate for each diagnosis

Definition of consultation

Process by which you seek the expertise of a specialist such as your nursing instructor, a physician, or a clinical nurse educator to identify ways to handle problems in pt management or in planning and implementing therapies

Example of outcome (expected)

Pt will rank pain as 0/10

Collaborative interventions use who

RT, PT, OT

Humility

Recognize when you need more information to make a decision

What do you provide the consultant with

Relevant information about the problem area. Summary, methods used to date, and outcomes

List factors that affect priority setting

Resources Policies and procedures Staffing Supplies Patient's condition

Critical pathways define what for each health care discipline

Responsibility

A, C The related factors in diagnoses "Fatigue related to heart disease" and "Need for improved oral mucosa integrity related to inflamed mucosa" are incorrect. The related factor of a medical diagnosis (in Fatigue related to heart disease) cannot be corrected through nursing intervention. In "Need for improved oral mucosa integrity related to inflamed mucosa" there is no diagnosis, but instead a goal of care. "Risk for infection related to surgery" is incorrect; risk nursing diagnoses do not have defining characteristics or related factors because they have not occurred yet.

Review the following problem-focused nursing diagnoses and identify the diagnoses that are stated correctly. (Select all that apply.) A. Impaired Skin Integrity related to physical immobility B. Fatigue related to heart disease C. Nausea related to gastric distention D. Need for improved Oral Mucosa Integrity related to inflamed mucosa E. Risk for Infection related to surgery

Secondary prevention

Screening, case finding, early diagnosis, treatment

How are expected outcomes written

Sequentially, with time frames

System

Set of objects or elements that interact to achieve a specific goal; has boundaries that separate them from other systems (Ex: heart muscle tissue, a family)

Usually, how many expected outcomes are developed for each nursing diagnosis

Several

SMART

Specific Measurable Attainable Realistic Timed

What are specific statements

Specific statements of pt behavior or physiological responses the nurse sets to resolve a nursing diagnosis

What did the Iowa Intervention Project publish

The Nursing Outcomes Classification which linked the outcomes to NANDA international nursing diagnoses

The nursing care plan enhances what

The continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care

Variance from wellness

The difference from the normal or usual wellness condition. Varying degree of system instabilty

2, 4, 5 The presence of abdominal pain, distention, and a change in bowel elimination pattern forms a cluster, suggesting an elimination problem.

The nurse completed the following assessment: 63-year-old female patient has had abdominal pain for 6 days. She reports not having a bowel movement for 4 days, whereas she normally has a bowel movement every 2 to 3 days. She has not been hospitalized in the past. Her abdomen is distended. She reports being anxious about upcoming tests. Her temperature was 37° C, pulse 82 and regular, blood pressure 128/72. Which data form a cluster, showing a relevant pattern? Select all that apply. 1 Vital sign results 2 Abdominal distention 3 Age of patient 4 Change in bowel elimination pattern 5 Abdominal pain 6 No history of hospitalization

3 The PES format stands for: problem (P), etiology or related factor (E), and symptoms or defining characteristics (S). In this case, the related factor is the incisional trauma.

The nurse identified that the patient has pain of 7 on a scale of 1 to 10; he winces during movement, and he expresses discomfort over the incisional area. He guards the area by resisting movement. The incision appears to be healing, but there is natural swelling. What would be the E in a three-part nursing diagnostic statement using the PES format? 1 Severe pain 2 Natural swelling 3 Related to incisional trauma 4 Wincing, guarding, restricted turning and positioning

3, 4, 1, 2 The initial step of the nursing diagnosis is to collect data about the patient from the patient, family, and healthcare resources. After the data has been collected and validated, then interpretation and analysis may occur. In data clustering, all the signs and symptoms are grouped in a logical way. The diagnostic label describes the essence of a patient's response to health conditions. After reviewing all the information, the patient's specific healthcare problems are identified.

The nurse is assessing a patient who has asthma. How would the nurse arrange the steps in the correct sequence for making a nursing diagnosis? 1. Data clustering 2. Selecting the diagnostic label 3. Assessing patient's health status 4. Validating data with other sources

3, 4, 5 Collaborative problems are actual or potential physiological complications that the nurse can monitor to detect the onset of changes in the patient's status. Hemorrhage, paralysis, and wound infections are collaborative problems. These problems require nursing and monitoring. Cold and nausea are not collaborative problems because they do not lead to multiple complications.

The nurse is assessing the patients on the unit. The nurse identifies some collaborative problems among the patients. What are some examples of collaborative problems? Select all that apply. 1 Cold 2 Nausea 3 Paralysis 4 Hemorrhage 5 Wound infection

Each goal must be what

Time limited, may last several hours to days

2, 3, 5 A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Weakness and dysuria aren't directly related to respiratory issues.

The nurse is caring for a patient who has been admitted to the hospital with pneumonia. Which assessment findings of the patient can the nurse group together to formulate a data cluster? Select all that apply. 1 Dysuria 2 Wheezing in left lung bases 3 Respiration 20 breaths/minute 4 Weakness of the entire body 5 Shortness of breath with ambulation

1, 3, 4 The components of cough, shortness of breath, and dyspnea or difficulty in breathing constitute the problem and symptoms seen in the patient. "Problems caused by smoking" gives the etiology of the disease. Medications that the person has to take, and the diet and regimen are not part of the PES approach.

The nurse is designing a care plan for a patient admitted to the hospital with pneumonia. The nurse is using the PES format (problem, etiology, and symptom) for formulating nursing diagnoses. Which components can the nurse include in this PES format? Select all that apply. 1 Cough and shortness of breath 2 Medications that the patient must take 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking 5 The diet and regimen to be followed in this disease

1, 2, 4, 5 According to NANDA-I diagnoses, related factors come in four categories: situational, maturational, treatment-related, and pathophysiological. A related factor is identified from the patient's assessment data. The related factor is associated with a patient's actual response to the health problem. It can be changed by using specific nursing interventions. According to the NANDA I diagnoses, psychological is not considered a category of related factors.

The nurse is identifying the related factors by studying a patient's assessment data. According to NANDA-I diagnoses, under which categories should the nurse classify the related factors? Select all that apply. 1 Situational 2 Maturational 3 Psychological 4 Treatment-related 5 Pathophysiological

1, 2, 5 Accurately interpreting and using reliable cues are ways to prevent errors in interpretation while making the nursing diagnosis. The nurse should also consider the influence of culture or developmental stage on the patient's health when formulating a nursing diagnosis. Failure to consider conflicting cues and using an insufficient number of cues may lead to misinterpretation and can lead to errors.

The nurse is preparing a nursing care plan. Which actions would most likely prevent errors in interpretation when making a nursing diagnosis? Select all that apply. 1 Accurately interpreting cues 2 Using reliable cues 3 Failing to consider conflicting cues 4 Using an insufficient number of cues 5 Considering cultural influences or developmental stage

2, 3, 4 The standard formal nursing diagnostic statements of the North American Nursing Diagnosis Association-International (NANDA-I) promotes the creation of practice guidelines that reflect the essence and science of nursing. They do not necessarily follow the traditional guidelines, which have been handed over through generations. The nursing diagnostic statements do not align the role of the nurse with other health care providers; rather, it distinguishes the nurse's role from that of other health care providers. Nursing diagnostic statements help nurses focus on the scope of nursing practice specifically, not medical practice as a whole. The nursing diagnostic statement essentially helps to foster the development of nursing knowledge. The nursing diagnostic statement allows nurses to communicate with each other in both written and electronic formats.

The nurse is teaching a group of nursing students about the use of standard formal nursing diagnostic statements from the North American Nursing Diagnosis Association-International (NANDA-I). Which statements by a student indicate the need for further learning? Select all that apply. 1 "The nursing diagnostic statements foster the development of nursing knowledge." 2 "The nursing diagnostic statements emphasize following traditional practice guidelines." 3 "The nursing diagnostic statements align the role of the nurses with other health care providers." 4 "The nursing diagnostic statements help the nurses focus on the scope of medical practice as a whole." 5 "The nursing diagnostic statements allow nurses to communicate among themselves in both written and electronic formats."

2, 4, 5 A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests. Osteoarthritis and diabetes mellitus are medical diagnoses, because these can be diagnosed by a healthcare provider through diagnostic tests and medical history. Medical diagnoses are based on the results of diagnostic tests. A primary healthcare provider is licensed to describe medical diagnoses and treat diseases. Acute pain is a nursing diagnosis. It can be easily identified by observing a patient's signs and symptoms and does not require any specific diagnostic test. A medical diagnosis does not include a clinical judgment about an individual and his or her family.

The nurse is teaching nursing students about medical diagnoses. Which statements by the students indicate effective learning? Select all that apply. 1 "Acute pain is a medical diagnosis." 2 "Osteoarthritis is a medical diagnosis." 3 "A medical diagnosis includes the clinical judgment about an individual and his family." 4 "Medical diagnoses are based on the results of diagnostic tests." 5 "A primary healthcare provider is licensed to describe medical diagnoses."

B This is an example of a problem-focused nursing diagnosis with a related factor, based on NANDA-I diagnostic terminology. Most health promotion diagnoses do not have established related factors based on NANDA-I; their use is optional. Wellness diagnoses are not one of the types of NANDA-I diagnoses.

The nursing diagnosis Impaired Parenting related to mother's developmental delay is an example of a(n): A. Risk nursing diagnosis. B. Problem-focused nursing diagnosis. C. Health promotion nursing diagnosis. D. Wellness nursing diagnosis.

What is UNIQUE to Neuman model?

The patient becomes part of the plan and together with the nurse, they develop the complementary perceptual understanding

A, C, E The use of nursing diagnosis creates a common language for nurses to communicate patient care needs, allows nurses to focus on the realm and scope of nursing practice, and helps to develop nursing knowledge. It is not a language for physicians and allied health staff because they do not rely on providing nursing interventions. Terminology in nursing diagnosis may be familiar to other health care providers but not in a way for directing nursing interventions. Nursing diagnosis has the purpose of creating practice guidelines for nursing.

The use of standard formal nursing diagnostic statements serves several purposes in nursing practice, including which of the following? (Select all that apply.) A. Defines a patient's problem, giving members of the health care team a common language for understanding the patient's needs B. Allows physicians and allied health staff to communicate with nurses how they provide care among themselves C. Helps nurses focus on the scope of nursing practice D. Creates practice guidelines for collaborative health care activities E. Builds and expands nursing knowledge

Extrapersonal stressors

Those that occur distally to the client system boundary (Ex: community resource)

A critical pathway clearly defines what

Transition points in pt progress and draws a coordinated map of activities by which the health care team can help to make these transitions as efficiently as possible

Nursing interventions

Treatments or actions based on clinical judgement and knowledge that nurses perform to meet pt outcomes

indirect care

Treatments performed away from the patient but on behalf of the patient or group of patients

Angiomas

Tumors consisting principally of blood vessels or lymph vessels

Created environment

Unconsciously developed by the client

1 A health promotion nursing diagnosis is a type of nursing diagnosis that indicates a person's readiness to enhance specific health behaviors for well-being. A human response to health conditions that may develop in a vulnerable individual is a risk nursing diagnosis. A human response to health conditions that exist in an individual or community is an actual nursing diagnosis. A potential response to the health problem that can change by using specific nursing interventions is a related factor.

What is a health promotion diagnosis, according to NANDA-I? 1 It describes a person's readiness to enhance specific health behaviors for well-being. 2 It describes human responses to health conditions that may develop in a vulnerable individual. 3 It describes human responses to health conditions that exist in an individual or community. 4 It is associated with a potential response to the health problem and can change by using specific nursing interventions.

3 An accurate nursing diagnosis helps ensure effective and efficient nursing interventions. Selecting the correct nursing diagnosis is based on proper assessment of the patient and proper analysis of the health problem. It enhances the nursing care provided to the patient. It does not decrease the side effects of the medicines or the cost of treatment. Further assessment after the nursing diagnosis is essential to evaluate the effectiveness of the activities performed.

What is the benefit of an accurate nursing diagnosis? 1 It decreases the side effects of medications. 2 It reduces the cost of treatment to the patient. 3 It helps ensure effective and efficient nursing interventions. 4 It prevents further assessment.

vasoconstriction

narrowing of blood vessels

Critical time

When nurses collaborate and share important information that ensures the continuity of care for a pt and prevents errors or delays in providing nursing interventions

Reconstitution

When you return to normal level of wellness. May stabilize the system to a lower level or return to level of wellness prior to illness.

Always determine what before implementing therapy

Whether it is appropriate for pt

4 Inaccurate understanding of cues is a diagnostic error related to interpretation. Inaccurate data and disorganization are diagnostic errors related to data collection. Failure to seek guidance is an error related to the labeling of data.

Which is an example of an interpreting error in nursing diagnostics? 1 Inaccurate data 2 Disorganization 3 Failure to seek guidance 4 Inaccurate understanding of cues

B, D The correct diagnoses of Sleep Deprivation and Ineffective Protection are worded with related factors that will respond to nursing interventions. Nursing interventions do not change a medical diagnosis or diagnostic test. Instead nurses direct nursing interventions at behaviors or conditions that they are able to treat or manage. The first two incorrect diagnoses use a medical diagnosis and diagnostic procedure respectively as related or etiological factors. These are not conditions that nursing interventions can treat. The last diagnosis is incorrect because it is related to an assessment finding of a symptom or a defining characteristic.

Which of the following nursing diagnoses is stated correctly? (Select all that apply.) A. Fluid Volume Excess related to heart failure B. Sleep Deprivation related to sustained noisy environment C. Impaired Bed Mobility related to postcardiac catheterization D. Ineffective Protection related to inadequate nutrition E. Diarrhea related to frequent, small, watery stools

nursing intervention

any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient outcomes

append/o

appendix

2 The question regarding how the health problem affects the patient and his or her family provides information regarding cultural practices followed by the family. The question regarding visiting the healthcare setting does not provide information about the cultural practices of the patient. Instead, it gives information regarding the patient's health status. The question about informed consent does not provide information regarding the patient's cultural practices. The question regarding the side effects of the medications does not reveal the cultural practices of the family. Instead, this question gives information regarding the patient's knowledge about the medications.

Which question does the nurse ask the patient with renal disorder while selecting nursing diagnoses relevant to the patient's culture? 1 "How often do you visit your healthcare setting?" 2 "How does this health problem affect you and your family?" 3 "What should you know before signing an informed consent?" 4 "Do you know about the side effects of the medications that you are using?"

myocele

condition in which muscle protrudes through its fascial covering

1, 2, 3 Inaccurate interpretation of cues, use of an insufficient number of cues, and failure to consider conflicting cues may cause interpretation errors and lead to inaccurate diagnoses. An insufficient cluster of cues does not directly cause interpretation errors but could result in errors in clustering of data. Similarly, failing to validate the nursing diagnosis with the patient does not directly cause interpretation errors but could result in a labeling error.

Which type of interpretation errors may occur with a nursing diagnosis? Select all that apply. 1 Inaccurate interpretation of cues 2 Use of an insufficient number of cues 3 Failure to consider conflicting cues 4 Failure to validate the nursing diagnosis with the patient 5 Insufficient cluster of cues

Neuman's Nursing process assessment includes:

Wholistic assessment of actual and potential stressors, client variables (age/gender), & boundary impact (stressors impact people differently)

infarction

necrosis of a localized area of tissue caused by lack of blood supply to that area

lifesaving measure

a physical care technique that you use when a patient's physiological or psychological state is threatened

standing order

a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems

apnea

absence of breathing

Cellulitis

acute, spreading inflammation of the deep subcutaneous tissues

Alveoli

air sacs in the lungs

Knowing the patient

an in-depth knowledge of a patient's patterns of responses within a clinical situation and knowing the patient as a person

evaluative measures

are assessment skills and techniques (e.g., observations, physiological measurements, patient interview)

Open systems:

are living system Have boundaries, interact with the environment and each other, dynamic, becomes more complex, input/throughput/output dynamic changes happen, with self regulation and self maintenance

Tendons

bands of strong fibrous tissue that attach the muscles to the bones

Perseverance

be cautious of the easy answer, bring co-workers together to look for a pattern and find a solution

pulmonary embolus

blood clot in the lung

sarcoma

cancers that arise from connective tissues (muscle/bone)

wrist bones

carpals

veins

carry blood back to the heart

Leukemia

chronic or acute disease of the blood forming tissue

tailbone

coccyx

rib

costa

skull

cranium

colostomy

creation of an opening of a portion of the colon through the abdominal wall to its outside surface

hypoxia/anoxia

deficiency of oxygen

Dyspenea

difficult or labored breathing

dysphonia

difficulty speaking

If goals are mutually set and a clear plan of action is decided, pts are more likely to what

fully participate in the plan of care

cholecyst/o

gallbladder

cholelithiasis

gallstones in the gallbladder

gingiv/o

gums

multiple myeloma

disease characterized by the presence of many tumor masses in the bone and bone marrow

cardiomyopathy

disease of the heart muscle

adult repiratory distress syndrome (ARDS)

disorder characterized by respiratory insufficiency and hypoxia

thrombolytic

drug that breaks down blood clots

antihypertnesives

drug used to reduce high blood pressure

Anti-emetics

drugs used to treat nausea and vomiting

3 parts of small intestine

duodenum, jejunum, ileum

Psychosocial

education level how does client cope how does client react to examiner

cardiomegaly

enlargement of the heart

hepatomegaly

enlargement of the liver

splenomegaly

enlargement of the spleen

developmental

eriksons stage of development what are the developmental tasks of this age what role does the client play in the family

esophag/o

esophagus

Problem solving

evaluating the situation over time, identifying possible solutions, and trying a solution over time to make sure that it is effective

polyphagia

excessive hunger

emaciation

excessive leanness caused by disease or lack of nutrition

polydipsia

excessive thirst

polyuria

excessive urination

myasthenia gravis

fatigue and muscle weakness resulting from a defect in condition of nerve impulses

Evaluation

final step of the nursing process, crucial to determine whether, after the application of the first four steps of the nursing process, a patient's condition or well being improves

Implementation

fourth step of nursing process; formally begins after you develop a plan of care

Myocardium

heart muscle

Hypertension

high blood pressure

Insulin

hormone that regulates the blood sugar level

upper arm bone

humerus

3 bones of pelvis

ilium, ischium, pubis

Illness is a state of insufficiency with disrupting needs unsatisfied.

illness is an excessive expenditure of energy, outcome may be death

aphasia

inability to speak

trachectomy

incision into the trachea

vasodilation

increase in diameter of a blood vessel

bronchitis

inflammation of the bronchi

colitis

inflammation of the colon

pericarditis

inflammation of the pericardium

pharyngitis

inflammation of the pharynx

pleurisy (pleuritis)

inflammation of the pleural membrane characterized by a stabbing pain that is intensified by coughing or deep breathing

sinusitis

inflammation of the sinuses

endocardium

inner lining of the heart

oximeter

instrument used to measure oxygen

diabetes mellitus

insulin is not secreted adequately or tissues are resistant to its effects

arrhythmia

irregularity or loss of rhythm of the heartbeat

phsiological

is mouth dry and cracked is breathing normal lost or gained weight

Patella

kneecap

Evidence-based knowledge

knowledge based on research or clinical expertise, making you an informed thinker

Scoliosis

lateral curvature of the spine

bradypnea

less then 12 breaths per minute (slow breathing)

cirrh/o

lips

hepat/o

liver

Creativity

look for different approaches if interventions are not working for a patient

anorexia

loss of appetite

hypotension

low blood pressure

mandible

lower jaw

bones of feet

metatarsals

Nursing care plan

nursing diagnoses, goals, expected outcomes, nursing interventions

Inter-personal stressor

occur between individuals. External environmental interaction forces occurring outside the boundary of the client

Extra-personal stressor

occur outside the individual. External environmental interaction forces occurring outside the boundary of the client at distal range.

Intra-personal stressor

occur within the person. Internal environmental interaction forces occurring within the boundary of the client.

quadrapelegia

paralysis of arms and legs

parapelegia

paralysis of lower portion of body and both legs

cardiac catheterization

passage of a long flexible tube into heart chambers through vein in arm, leg, or neck

biliary tract

pathway for bile flow from the liver to the bile duct and into the duodenum

Patient adherence

patients and families invest time in carrying out required treatments

breastbone

sternum

fingers and toes

phalanges

interdisciplinary plans

plans representing the contributions of all disciplines caring for a patient

rhinoplasty

plastic surgery of the nose

Preventive nursing actions

promote health and prevent illness to avoid the need for acute or rehabilitative health care

gastr/o

stomach

gallstone

stone formed in the biliary tract

Integirty

recognize when your opinions conflict with the patient and decide how to proceed to reach outcomes that will satisfy everyone

echocardiagram

record of heart obtained by ultra sonic waves through the chest wall

Ligaments

strong bands of fibrous connective tissue that connect bones or cartilage and support the joints and joint movement

Clinical decision making

requires careful reasoning choosing the options for the best patient outcomes on the basis of a patient's condition and the priority of the problem

tahcypnea

respiration exceeds 20 breaths per min (fast breathing)

Perception can influence a client's _________ & _________ to a stressor

response & resistance

cardioversion

restoration of a normal heart rhythm by electric shock

herniated disk

rupture of an intervertebral disk

instrumental activities of daily living (IADLs)

shopping, housework, money management, meal preparation

Bronchioles

smallest branches of the bronchi

heart murmur

soft blowing or rasping sound that may be heard when listening to the heart with a stethoscope

glottis

space between the vocal chords; opening to larynx

ankle bones

tarsals

dent/i, dent/o, odont/o

teeth

Critical thinking

the ability to think in a systematic and logical manner with openness to question and reflect on the reasoning process a reasoning process where you reflect on and analyze your thoughts, actions, and knowledge

standard of care

the minimum level of care accepted to ensure high quality of care to patients

Inference

the process of drawing conclusions from related pieces of evidence and previous experience with the evidence

femur

thigh bone

Pharynx

throat

Aim of Neuman system model:

to set a structure that depicts the parts and subparts and their interrelationship for the whole of the client as a complete system

direct care

treatments performed through interactions with patients

sublingual

under the tongue

activities of daily living (ADLs)

usually performed in the course of a normal day; they include ambulation, eating, dressing, bathing, and grooming

spinal bones

vertebrae

bronchoscopy

visual examination of the bronchi

colonoscopy

visual examination of the colon

Concept map

visual representation of patient problems and interventions that shows their relationships to one another -the purpose is to get relevant data about the patient, like assessment data, diagnoses, health needs, interventions, and evaluation measures

Arteries

what blood leaves the heart through

sociocultural

what is cultural background any genetic risks for illness in this group how does the person compare to norms

spiritual

what religious practices are important to the patient does the patient read religious material or pray has illness stressor made a difference in the perception of God

Fibromyalgia

widespread non-articular pain of the torso, extremities, and face

trachea

windpipe