ch 4, 5, 6, 7 fundamentals

What should the nurse who is performing an admission interview on an elderly person do?

allow them more time to understand what you are saying and to ask questions

What does a nursing care plan consist of?

nursing orders for individualized interventions to assist the patient to meet expected outcomes. -goals/expected outcomes -nursing interventions -selected rationale -evaluation

What are nursing orders also called?

interventions

What is evaluation?

is carried out by gathering data to determine whether expected outcomes have been achieved. when interventions are not leading to expected outcomes, what needs to be done is reconsidered. aspects of the care plan are modified or terminated as appropriate

What is the general rule for the initial care plan for a patient?

it is developed by the RN in an acute care setting

How does the nurse design the goals of a patient in long-term care?

they would get long term goals

Why does the nurse document in the nurses' notes?

to indicate that the nursing care plan has been implemented

When prioritizing patient care, consideration is given to?

what level of priority each patient is. -Life threatening problems are are high priority -medium priority is problems that threaten health or coping ability -low priority problems are ones that do not have a major effect on the person if not attended to that day or even that week -Priority setting (prioritizing): placing nursing diagnoses/interventions in order of importance -priorities change constantly because patient needs and conditions change frequently

What is an appropriate intervention for a person with visual impairment?

A patient with visual impairment is identified as at risk for falls related to blindness. An appropriate intervention would be to arrange furnishings in room to provide clear pathways and orient the patient to these.

what is the nursing process?

-A way of thinking and acting based on the scientific method -Used as a tool identify patients' problems and an organized method to meet patients' needs Components: -Assessment (data collection) -Nursing diagnosis -Planning -Implementation -Evaluation

What is the major goal of the admission interview?

-Based on gathering data—is not a social interaction -Good communication essential -Communication may be: --Verbal --Nonverbal, noting body posture, facial expressions, movement, and gestures Consists of three basic stages 1. The opening, during which rapport is established with the patient 2. The body of the interview, during which necessary questions are presented 3. The closing, during which information is summarized -identify the patients major complaints

What does the nurse do during the assessment phase of the nursing process?

-During assessment, the nurse collects patient health data -Data are gathered on specific topics, organized into a database, and documented -LPNs/LVNs may be asked to collect data as part of the assessment

The activity that is implementation in nursing care is what?

-Implementation involves preparing for and performing the interventions -preparing and performing the interventions. equipment and supplies are gathered and procedures are thought through before beginning them. interventions are performed and responses to them are assessed.

What is a Kardex and what information can you obtain from it?

-Not a part of the permanent medical record -A quick reference for current information about the patient and ordered treatments -Usually consists of a folded card for each patient in a holder that can be quickly flipped from one patient to another -Room number, patient name, age, sex, admitting diagnosis, physician's name -Date of surgery -Type of diet ordered -Scheduled tests or procedures -Level of activity permitted -Notations on tubes, machines, other equipment in use -Nursing orders for assistive or comfort measures -List of medications prescribed by name -IV fluids ordered

Know how to thoroughly document a pain assessment.

-When charting a sign or symptom, the nurse should include the quality (level 7 to 8), chronology (after lunch, last 3 hours), and aggravating or alleviating factors, as well as associated symptoms. -example: Peri-umbilical sharp pain at pain level of 7 to 8 for last 3 hours, started 2 hours after lunch. No relief from antacids.

What are the responsibilities of the LPN for a patient's plan of care? (SATA)

-collect data -perform nursing interventions -assist the RN with evaluation of the patients response to nursing interventions

What is critical thinking? (Completion)

-conclusions that have been made based on observed data are inferences. -critical thinking is directed, purposeful, mental activity by which you create and evaluate ideas, analyze data, anticipate problems, use expansive thinking, reflect on experience, construct plans, and determine desired outcomes.

Know what a dependent and an independent nursing action is.

-independent nursing action does not require a primary care providers order but does require clinical judgement and critical thinking. -dependent nursing actions require a PCP order

Be able to prioritize nursing diagnosis.

-physiological needs for basic survival takes precedence -airway comes first always -circulation is next -patient in pain will get pain medicine before food -after physiologic needs are met safety problems take priority -then psychosocial needs of love and belonging, self esteem, and self actualization are given attention

What should an expected outcome be? (SATA)

-realistic -attainable -within a defined time -included after patient collaboration

What is the difference between a sign and a symptom?

-signs are abnormalities that can be verified by repeat examination and are objective data. ex: bruise -symptoms are factors that the patient said are occurring that cannot be verified by examination they are subjective ex: headache

What is an example of a time-flexible task?

-tasks that can be done at any time ex: brushing hair

What should the nurse document if a patient meets a goal?

-that the outcome has been met and mark the nursing diagnoses as resolved -resolved problems are inactivated and new problems added -interventions revised

The nursing care plan is always a ___________________ and will change as ____________________.

-work in progress - the patient's condition changes

What is the first step in problem solving?

1. define the problem clearly 2. consider all possible alternative solutions to the problem 3. consider all possible outcomes for each alternative 4. predict the likelihood of each outcome occurring 5. choose the alternative with the best chance of success and the fewest undesirable outcomes

Read over initial dressing change.

The general rule is that the initial dressing change is performed by the surgeon who will give further orders pertinent to future dressing changes. The dressing should be reinforced with sterile materials; findings should be documented and reported to the charge nurse.

The examination to confirm and affirm a complaint is ______________________.

an assessment -Collecting, organizing, documenting, and validating a patient's health data -Data are gathered from patient (physical assessment and interview) and family, as well as from the physician and patient's medical record -Data from other health professionals and diagnostic tests included in assessment

The order of assessment, nursing diagnosis, planning, implementation and evaluation sets up a basis for _______________________________________.

an organized approach to nursing.

The nurse should always finish the assessment in order to _________________________________________.

confirm the complaint and inform the charge nurse

Know how to correct an error on a chart.

draws a single line through the notation so that it is still readable and writes mistaken entry, his signature, and the date and time.

How often is the NANDA list revised?

every 2 years

How often is the nursing care plan reviewed and updated in the acute care facility?

every 24 hours

How do you develop critical thinking skills?

page 51 -concept mapping helps students learn to synthesize pertinent assessment data, develop comprehensive care plans, link nursing interventions with health problems and nursing diagnoses, and effectively implement the care plan. -critical thinking in nursing requires skills and experience as well as knowledge. studies demonstrate that nursing professionalism influences a nurses critical thinking ability. -a positive self concept is also linked to problem solving and critical thinking ability. -listening attentively and focusing on the speakers words and meaning.

What does the nurse do if a patient has several nursing diagnosis?

prioritize the nursing problems according to Maslow's hierarchy of needs.

What does a nursing diagnosis consist of?

problem (stem) + etiology (causative factors) + signs and symptoms (as evidence by) nursing diagnoses define the patients response to the illness while dr diagnoses label the illness

What should the inexperienced nurse do prior to performing any procedure?

review the agency's procedure manual for the accepted way of performing the procedure

What do short-term goals consist of? Be able to recognize one.

short term goals are those that are achievable within 7 to 10 days or before discharge, whereas long term goals take weeks or months to achieve

Know the difference between subjective and objective data.

subjective: data obtained from the patient verbally that only the patient can describe or verify objective: info obtained through the senses and hands on physical exam

What does the LPN do to assist the RN in selecting a nursing diagnosis?

the LPN is often responsible for data collection to assist the RN with the assessment phase

how is a nursing diagnosis established?

the process by which the assessment data are sorted and analyzed so that specific actual and potential health problems are identified. the factors contributing to the problems are considered, and the specific nursing diagnoses are chosen for the patients care plan. -Sorting and analyzing the assessment data to identify potential health problems -Problems identified during the process are specific nursing diagnoses -Nursing diagnoses prioritized and entered into the nursing plan of care