nur1025 test 1
What are the necessary components of patient goals/desired outcomes and nursing interventions?
Goals/ Desired outcomes ( SMART) Specific - indicate how the nurse will know that the client's response has changed Measurable - address what the client will do, when this will be accomplished, and to what extent Appropriate- include client in formulating outcomes Realistic- consider client's present and potential capabilities Time frame- include a time estimate for outcome achievement Nursing Intervention Specific - Example: Give fluid 2000 ml per day 7-3pm - 1000 mL 3-11pm - 900 mL 11-7am - 100 mL 2000 mL
19. What is validation of data collected in the assessment step of the nursing process? 242
-Validation of assessment data is the comparison of data with another source to determine data accuracy. Validation is done before you begin analyzing and interpreting data. It helps clarify vague or unclear data. Validate data directly with the client, or/and by physical examination and observation of client behavior by comparing data in the medical record, by consulting with other nurses or health care team members, and also by consulting with family and friends.
What are the three types of nursing interventions?
1. Nurse Initiated: Independent interventions, or actions that a nurse initiates. They do not require direction or an order from another health care professional. As a nurse, you act independently on a client's behalf. Nurse initiated interventions are autonomous actions based on scientific rationales. Examples include: Elevating an edematous extremity Instructing clients in side effects of medications Directing a client to splint an incision during coughing Activities of daily living Health education and promotion Physical care -teaching Ongoing assessment -counseling Emotional support & comfort Environmental management Making referrals to other health care professionals Such interventions benefit a client in a predicted way related to nursing diagnosis and client goals. They do not require supervision or directions from others. 2. Physician initiated: dependent nursing interventions, or actions that require an order from a physician or another health care professional. The interventions are based on the physician's or health care provider's response to treat or manage a medical diagnosis. As the nurse, you intervene by carrying out the independent provider's written and/or verbal orders. Administering a medication, implementing an invasive procedure, changing a dressing, and preparing a client for diagnostic tests are examples of physician- initiated intervention. Each physician- initiated intervention requires specific nursing responsibilities and technical nursing knowledge. • Example includes: When administering medications, the nurse is responsible for knowing the classification of the drug, its physiological action, normal dosage, side effects, and nursing intervention related to its action or side effects. With an invasive procedure, you are responsible for knowing when the procedure is necessary, the clinical skills necessary to complete it, and its expected outcome and possible side effects. You are also responsible for adequate preparation of the client and proper communication of the results. You perform dependent nursing interventions, like all nursing actions, with appropriate knowledge and good clinical judgment. 3. Collaborative Intervention: or interdependent nursing interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care professional such as physical therapists, social workers, dietitians, and physicians . Typically, when you plan care for a client, you will review the necessary interventions and determine if the collaboration of other health care disciplines is necessary.
13 Define activity intolerance as a nursing diagnosis and discuss ways to assess for it. How does the nurse treat it? 1236
Activity Intolerance is insufficient physiological or Psychological energy to endure or complete required or desired daily activities. Subjective: • Verbal report of fatigue / Weakness • Exertional discomfort/ dyspnea • No desire or lack of interest in activity Objective: • Abnormal HR, or BP response to activity. • EKG changes reflecting arrhythmia or ischemia • Pallor/ Cyanosis Assess: • Assess factors contributing to fatigue (age, heart failure, acute or chronic illness, hypothyroidism, cancer, or cancer therapies • Assess client actual and perceived limitations • Provide comparative baseline and info about needed education or intervention regarding quality of life • Note clients report of weakness, fatigue, pain, difficulty accomplishing tasks, insomnia. • Identify activity needs vs desire • Ascertain ability to stand and move about and degree of assistance necessary or use of equipment • Assess cardio pulmonary response to physical activity including vital signs before, during and after activities. • Assess emotional / psychological factors • Note any treatment related factors (side effects of meds) Nursing Treatment: Once you identify the nursing diagnosis, nurse should follow a plan of care: • Monitor vital and connective signs, watch for BP, HR, RR changes. • Adjust activities to prevent overexertion. • Increase exercise activity level gradually • Note skin pallor/ cyanosis and presence of confusion • Reduce intensity level or discontinue activities that cause undesired physiological changes. • Provide and monitor response to supplemental O2, medication, changes in treatment regimen. • Teach methods to conserve energy stopping for 3 min during a 10 min walk for ex. or sit to brush hair vs standing. • Plan care to carefully balance rest periods with activities to reduce fatigue • Provide + atmosphere while acknowledging difficulty of situation- • Encourage expression of feelings to cond. • Involve client in planning of activity • Assist with activity
4. Describe the chain of infection. Outline each link in the chain of infection. Give examples about how specific diseases are spread.
All emements need to be present for chain of Infection a. Infectious agent or pathogen Microorganism (Bacteria, viruses, fungi, protozoa) Factors for microorganism to cause disease Dose -sufficient number of organism Virulence- ability to survive in the host or outside body • Ability to enter and survive host Host Resistance Susceptibility of host b. Reservoir or source for pathogen growth - A place where a pathogen can survive but may or may not multiply. Types: • Human body (most common) • Animals, insects • Water, food • Inanimate objects Require proper environment to thrive ( grow) - Food, Oxygen, water , temperature( 20- 43 C or 68-109F ( ideal for human pathog.) PH ( ideally 5-7) , light ( like darkness) c. Portal of exit from reservoir Such as skin, resp. tract, Urinary tract, gastro tract, reproductive and blood. d. Mode of transmission (question 5) Contact Direct :fecal, oral Indirect: inanimate objects needles, sharps, dressings Droplet - Coughing sneezing talking large particles traveling up to 3 ft Aibourne- coughing - sneezing supended in air Vehicles- Contaminated items, drugs, solutions, blood Vectors - Insects e. Portal of entry from host ( same as exit) f. Susceptible host : susceptibility depends on the individuals degree of resistance to a pathogen (immune response). An infection does not occur until an individual becomes susceptible to the stre ngth and number (dose) of the microorganism capable of producing infection. The more virulent an organism, the greater the dose, the more likely a person will develop an infection. Factors that influence susceptibility (resistance) include; age, nutritional status, presence of chronic disease, trauma & smoking.**
12 Define the benefits of bedrest and the definition of the word bedridden. 1225
Bed rest: • reduces physical activity • reduces oxygen needs of the body • reduces pain, including postoperative pain or after acute injury to the lower back • allows ill or debilitated patients to rest • allows exhausted patients the opportunity for uninterrupted rest Bedridden: Meaning: A person confined to bed by illness or infirmity ( weakness) **
Intervention
Carrying out the planned nursing interventions the Major actions: 1. Reassess the client to update database 2. Determine need for nursing assistance 3. Perform or delegate planned nursing interventions 4. Communicate what nursing actions were implemented 5. Document care and client responses to care 6. Give verbal report as necessary Purpose: • To assist the client to meet desire goals/outcomes • Promote wellness • Prevent illness and disease • Restore health • Facilitate coping with altered functioning
16 What are the nursing interventions that will prevent skin breakdown? Define the 4 stages of pressure ulcers. What are the components necessary for the development of a decubitus ulcer Ex. Friction or sheer, decrease nutrition?1287-1294
Asses the client's risk factors Risk factors Assessment • Decreased sensory perception: decreased in the ability to respond to pressure related discomfort. • Moisture : degree to which the skin is exposed to moisture • Fecal and urinary incontinence • Friction & shear • Decreased activity/mobility: degree of physical activity • Nutritional status: usual food intake patterns Pressure ulcer risk assessment must be done systematically. Pressure ulcer risk assessment instruments including the: • Braden Scale • Gosnell Scale • Norton Scale Intervention Three major areas of nursing interventions: 1. Skin care (Assessment and skin hygiene are the 2 initial defenses for preventing skin breakdown) 2. Mechanical loading and support devices (which includes proper positioning and the use of therapeutic surfaces or devices 3. Education Nursing interventions according to the risk factor: Risk factor: Decreased sensory perception Nursing intervention: • Asses pressure points (such as occipital bone, scapula, spinous process, elbow, hips, sacrum, heel, sole, thigh, etc) for signs of non blanching reactive hyperemia • Intervention of proper alignment to reduce pressure Risk factor: Incontinence, moisture, skin hygiene Nursing intervention: • Asses need for incontinence management. o Patients who are incontinent of urine and/or feces must have an adequate evaluation to identify whether reversible causes exist. (Urinary tract infection, medications, confusion, fecal impaction, restricted mobility due to restraints...) o Make an effort to control, contain or correct incontinence. o You can treat urinary incontinence with behavioral techniques (bladder training and habit training), medication, and surgery. o Following each incontinence episode, cleanse area, dry and apply a thick layer of moisture barrier. It protects the skin from excessive moisture and bacteria. • Skin care / Cleaning: o When you clean skin, avoid soaps and hot water o Use cleanser that are not gentle to the skin o Excessive friction and scrubbing are contraindicated. Aggressive massage, especially over bony prominences has been shown to cause tissue damage, and must be avoided.. o After you clean the skin make sure it is COMPLETELY DRY o Apply moisturizer to keep the epidermis well lubricated but not oversaturated. Risk factor: decreased activity, immobility, friction and shear, nutritional status Nusing intervention: • Positioning o A individualized turning schedule o Patients need repositioning at least every 2 hours on a schedule. Some patients are able to sit. o For positioning, the "rule of 30" is used: The head of the bed is elevated to 30 degrees or less (Figure 1) And t 30-degree body laterally inclined position (Figure 2). o Prevent friction and shearing forces by using a transfer device to lift rather than to drag such as (lift sheets, trapezes, or mechanical lifts. • Support surfaces: Are specialized device for pressure distribution designed. (Such as therapeutic beds or mattresses) • Nutrition o Important for maintaining tissue integrity. o Consult dietitian for nutritional evaluation. o Provide adequate nutritional and fluid intake; assist with intakes as necessary. (ex: assist with meals, elevating bed, etc). o When, despite these measures, patients are unable to consume adequate amounts of nutrients, tube feeding or parenteral alimentation should be considered.
Question #17-2, 3, and 4: Define each step of the nursing process. What major actions happen in each step? What is the purpose of each step?
Assessment: The gathering and analysis of information about the client's health Book definition: Assessment is the deliberate and systematic collection of data to determine a client's current and past health status and functional status and to determine the client's present and past coping patterns. Major actions: 1. Data Collection and verification of data: o Collection of data from a primary source (the client) and secondary sources (family, health professional team and medical records) o Determine what questions or measurements are appropriate o Differentiate important data from the total data collected o Cue: is information that you obtain through use of the senses (signs and symptoms) o Inference: is your judgment or interpretation of those cues. 2. Interview and nursing health history: o Interview : is an organized conversation with client o Nursing health history: includes data about the client's current level of wellness, including a review of systems, family health history, socio-cultural history, spiritual beliefs, mental and emotional reaction to illness. Parts of the interview: Orientation phase: o Introduce yourself to client o Explain role o Explain purpose of the interview o Assure them that any information obtained will remain confidential o Establish a caring therapeutic relationship with patient (establish trust & confidence) o Get insights about client's concern and worries Working phase o During the working phase, obtain a nursing health history about the client's health status o Explore the client's current illness, health history, expectations of care o Use communications strategies such as listening, paraphrasing and summarizing to promote clear interaction. o The uses of open-ended questions, encourages clients to tell their story in details Termination phase o Give a client a clue that the interview is about to end o Summarize the important points and ask whether the summary o End friendly in a friendly manner 3. Conduct a physical assessment • Physical assessment: is an investigation of the body to determine health status. Involves use of techniques: inspection, palpation,smell,percussion, acusltation. A complete examination includes height, weight, vital signs, an head to toe examination of all body systems. 4. Review clients records 5. Review nursing literature 6. Consult health professionals 7. Update data as needed 8. Organize data 9. Validate data 10. Communicate / document data Purpose: To establish a database about the client's response to health concerns or illness and the ability to manage healthcare needs. Diagnosing: Nursing diagnosis: is a clinical judgment about individual, family, or community responses to actual and potential health problems or life process. Nursing diagnosis classifies health problems within the domain in nursing. Forming diagnostic conclusions that determines the nursing care a patient receives. Diagnostic conclusions include problems treated primarily by nurses (nursing diagnoses) and problem requiring treatment by several disciplines (collaborative problems). Major actions: 1. Compare data against standards 2. Cluster or group data ( generate tentative hypotheses) 3. Identify gaps and inconsistencies 4. Determine client's strengths, risk and problems 5. Formulate nursing diagnoses and collaborative problem statements 6. Documents nursing diagnosis in the care plan. Purpose: • To indentify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. • To develop a list of nursing diagnoses and collaborative problems
15 What health problem affects nurses most in the work environment? 1244
Back injuries are most common in the nursing work environment related t: • Lifting • transferring or positioning immobilized client • Poor body mechanics.
5. Outline transmission of disease (direct contact, airborne, etc.) in people. (see below) 642
Direct: hepatitis A, shigella staphylococcis Indirect: Hepatitis B and C, HIV MRSA Psedumonas Respiratory Staphylococcus Droplet: (R.I.M.) Rubella Influenza Meningistis Airborne: (Mcat) Measles Chincken pox Aspergillus tubercolosis **
9. Types of Restraints. Discuss the types of restraints and how often does the nurse check a patient with restraints? 834-835
Check every 30 minutes patients with restraints. Do not place over IV lines or devices. RESTRAINT RATIONALE Belt Restraint: Device that secures client to bed or stretcher. Apply over clothes or gown. Restraints center of gravity and prevents client from rolling of the stretcher or sitting up while on stretcher or from falling out of bed. Tight application interferes w/ ventilation. Extremity Restraint: (Ankle or Wrist): Restraint designed to Immobilize one or all extremity Maintains immobilization of extremity to protect client from injury from fall or accidental or accidental removal of therapeutic device ( eg. IV tube or Foley Catherer. (tight application interferes with circulation Mitten Restraint: Thumbles mitten device to restrain client's hand. Prevents clients from dislodging invasive equipment, removing dressings or scratching, yet allows greater movement the a wrist restraint Elbow Restraint: Piece of fabric w/ slots in which tongue blades are place so that elbow joints remain rigid. Commonly used w/infants and children to prevent elbow flexion (eg when IV line is in place) Mummy Restraint: Open blanket or sheet on bed or crib with one corner, (fasten securely w/ safety pins) Maintains short- term restraint of small child or infant for examination or treatment involving head and neck. Effectively controls movement of torso and extremities. Note: A less restrictive restraint is the Posey Bed
14 How does the nurse assess for DVTs (Deep Vein Thrombosis)? What does the nurse do if the patient develops it? How does the nurse intervene to prevent it?1247 (pocket G 1053)
DVT assessment- Because DVT is a hazard of immobility, nurse should assess the venous system. More than 90% of all pulmonary emboli begin in the deep veins of the lower extremities. Then, to assess for a Deep Vein Thrombosis, nurse should: • Remove the client's elastic stockings and/or sequential compression devices (SCDs) every 8 hours and observe the calves for redness, warmth, and tenderness. • Measure bilateral calf circumference and record it daily: mark a point of each calf 10 cm down from the midpatella. Unilateral increases in calf circumferences are an early indication of thrombosis. • Because DVT also occurs in the thigh, take thigh's measurements daily if the client is prone to thrombosis. • Assess risk for thrombosis, assess for onset of intense or sharp pain with increase with sharp dorsi-flexion of foot. Assess for increased warmth, swelling, redness, dependent cyanosis and tenderness to palpation. ( Verify if Correct) If the patient develops DVT nurse should: • Report suspected DVTs immediately to the client's health care provider. • Elevate the leg, but avoid pressure on the thrombus. • Do not use Ted hose because it will make it worse • Instruct the family, client, and all health care personnel not to massage the area because of the danger of dislodging the thrombus. • Patient will need IV therapy such as Lovanox at a hospital setting. Nurse intervention to prevent DVT: The most cost-effective way to address DVT problem is through the aggressive program of prophylaxis. (The most widely use drug is Heparin -low molecular weight heparin is an anticoagulant) • To prevent a DVT from forming is by identifying the clients at risk. • Leg foot and ankle exercises • Regularly providing fluids • Position changes and client teaching once the patient becomes immobile. • Give information prior to surgery • Get them up as soon as possible after surgery. Begin use of intermittent Pneumatic compressions ( IPC), sequential compression device SCD's or elastic stockings TED hoses to promote venous return. These require health care provider's order.
16-3: What are the components necessary for the development of a decubitus ulcer?
Decubitus ulcer is a pressure sore or what is commonly called a "bed sore" Pressure ulcers can develop within 2 to 6 hours. Mechanisms of formation • Pressure: Any area of tissue that lies just over a bone is very likely to form a pressure ulcer because obstruct healthy capillary flow. • Friction and shear: from friction by rubbing against something such as a bed sheet, cast, brace, etc., or from prolonged exposure to cold. • Weight: The weight of the person's body presses on bones, the skin and tissue This situation compresses the blood vessels in the skin and underlying tissues. This tissue then begins to decay from lack of blood circulation. • Nutrition: A contributing factor to the development of pressure ulcers is an altered nutritional state [poor nutrition, weight loss, diabetes, etc.]. • Additional contributing factors are: poor hygiene, dehydration and immobility sometimes as a result of a poor standard of nursing care. • Tissue perfusion: Clients with shock or peripheral vascular diseases such as Diabetes are at risk for poor tissue perfusion due to poor circulation. Diabetes is not a cause of pressure ulcers but rather unrelieved pressure is the cause.
Planning:
Determining, how to prevent, reduce or resolve the indentified client's problems. How to support client's strengths and how to implement nursing interventions in a organized, individualized, and goal directed manner. Major actions: 1. Set priorities and goals / outcomes in collaboration with client 2. Write goals /desired outcomes 3. Select nursing strategies / interventions 4. Consult with other health professionals 5. Write nursing orders and nursing care plan 6. Communicate care plan to relevant health care providing Purpose: Develop and individualized plan that specifies client's goals and desire outcomes and related nursing interventions.
During which step of the nursing process does the nurse document what is done to and for patient?
Implementation
1. Describe the hospital precaution (policy) that all healthcare workers observe to prevent self-contamination from contact with patients in the healthcare setting. P. 655
Standard Precautions are to prevent and control infection and its spread for all blood and body fluid except sweat even if blood is not present as directed by OSHA. Precautions are: • Hand washing (most important and effective) • Hand hygiene includes: Instant alcohol hand antiseptic before and after providing client care when not visibly soiled. • Hand washing with soap and water when visibly soiled (15 seconds). • Performing surgical scrub • Use of gloves • Use of mask during a dressing change • Eyewear where there is a possibility of splash or splatter. **
21What is the difference between medical and nursing diagnoses?
Medical diagnoses Nursing diagnoses Identification of a disease condition based on a specific evaluation of physical signs, symptoms, the client's medical history, and the results of diagnostic tests and procedures. Clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. It is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and competent to treat. It provides the basis for selection of nursing intervention to achieve outcomes for which the nurse is accountable. • It is important to distinguish nursing diagnoses from medical diagnoses. The two are similar because they are both designed to plan care for a patient. However, nursing diagnoses focus on human response to stimuli, while medical diagnoses focus on the disease process. • An example of this difference is the different diagnoses given by a nurse and a doctor to a patient who exhibits difficulty breathing, a productive cough, and crackles throughout lung fields. This patient might be medically diagnosed as having pneumonia. Some nursing diagnoses that might be made for this particular patient, however, include activity intolerance, impaired gas exchange, and fatigue.
2. p.646-647 What are the specific and non-specific body defenses against diseases? Be able to identify them (Examples: cilia in the lungs (nonspecific) or lymphocytes (specific).)
Non specific - protect against microorganism regardless of prior exposure. Normal flora - Participates in maintaining health Body system defenses • Skin- multi layered surface, sebum, shedding of outer layer of skin • Respiratory tract - cilia and moist mucous membrane • Gastro tract- acidity of gastric secretion, rapid peristalsis in small intestines • Eye - tearing and blinking • Urinary tract - flushing action of urine flow, multi layered epithelium • Vagina - at puberty: vaginal secretions to achieve low PH Inflammation - Inflammatory response protective reaction that serves to neutralize pathogens or dead (necrotic) tissue and repairs body cells. Specific- against specific pathogens Vascular and cellular responses Phagocystosis - destruction and absorption of bacteria. (Causes fever) WBCs (neutrophils and monocytes) inject and destroy microorganism and small particles. Leukocytosis- Increased # of WBCs leaving the blood vessels - normally 5,000-10,000 15,000- 20,000 during inflammation
6. What are iatrogenic and nosocomial infections? Give examples. 644-645
Nosocomial infections - Health care acquired infections resulting from delivery of health services in a health care facility. Iatrogenic infections- A type of Nosocomial infection (doctor induced) - Are a type of health care associated infection (HAI) from diagnostic or therapeutic procedure. For ex. Following a gastrointestinal endoscopy developing P.aeruginosa (bacteria) infection. **
17 What is the nursing process? Define each step of the nursing process. What major actions happen in each step? What is the purpose of each step? 1231
Nursing Process: is a professional's nurses approach to indentify, diagnoses and treat human responses to health and illness Phases of the nursing process include: • Assessment of the patient's needs • Diagnosis of human response needs that nurses can deal with • Planning of patient's care • Implementation of care • Evaluation of the success of the implemented care
10 What is orthostatic hypotension and how does the nurse prevent it? 1227,1247
Orthostatic hypotension is an increase of heart rate of more than 15% and a drop of 15mmHg or more in systolic blood pressure, or a drop of 10 mmHg or more in diastolic blood pressure from supine to standing. Severe symptoms may cause fainting. Prevention: The nurse must instruct the patient to avoid getting up too quickly, to sit on the side of the bed for a few seconds prior to standing and to stand at the side of the bed for a few seconds prior walking. Mobilize the client as soon as the physical condition allows it , even if this only involves dangling at the bed side or the chair (rationale: increase muscle tone and the venous return)**
8. What are the causes for patients to incur injury in the hospital? 651
Physical Hazards - Falls are the leading cause of unintentional death in older adults. Leading admissions trauma for older adults (90% of fracture are due to falls in older adults) Lighting - well lighted hallways, bathrooms, night light Obstacles- Avoid doormats, small rugs, wet spots, clutter, Intrinsic - illness drug therapy, alcohol Extrinsic- Enviromental factors Bathroom hazard -avoid scalding, use hand bars, elevated toilet w/ arm rest. Medication- flush outdated meds, child-proof meds Security - smoke and fire detectors, Carbon monoxide detectors. Fires in the health care facilities are usually due to problems related to electrical or anesthetice equipment. In case of fire follow the Race Rescue Alarm Close windows and doors Extinguish In health setting - Falls- Client attempting to get out of bed to toilet and medicated patients. Client Inherent Accidents- self inflicted cuts, injuries and burns. Seizure induced Procedure related accidents- during therapy, medication and fluid administration errors improper application of external devices. Improper performance of procedure ex. Foley catheter insertion. Equipment related - malfunctioning equipment
22 What is a potential (risk) and an actual nursing diagnosis? What are the three types of nursing interventions? What are the necessary components of patient goals/desired outcomes and nursing interventions? What is the difference between short and long term goals? During which step of the nursing process does the nurse document what is done to and for the patient? What happens to the care plan if patient goals are not met?
Potential risk Nursing diagnosis Actual nursing diagnosis describes human responses to health conditions/ life processes that will possibly develop in a vulnerable individual, family, or community. For example, after Ms. Devine has the laminectomy, she will have a surgical incision. The hospital environment poses a risk for nosocomial infections. Thus the nurse chooses the nursing diagnosis of risk for infection describes human responses to health conditions or life processes that exist in an individual, family or community. Defining characteristics (manifestation, signs and symptoms) that cluster in patterns of related cues or inferences support this diagnostic judgment.
11.Which patients would be at risk for the hazards of immobility? 1227-1229
Pt at Risk for Hazard of Immobility • Age: Elderly patients • Postural abnormalities - congenital or acquired postural abnormalities. Torticollis, Lordosis, Kyphosis, Scoliosis, congenital hip dysplasia, knock knee, bowleg, clubfoot • Impaired Muscle Development- Muscular dystrophy • Damage to CNS - (Cerebrovascular accident CVA) • Direct Trauma to the musculoskeletal system. Fracture, sprains, contusions , bruises**
What is the difference between short and long term goals?
Short term Long term Objective behavior or response that you expect a client to achieve in a short time, usually less than a week. In an acute setting, you set goals for over a course of just a few hours. Objective behavior or response that you expect a client to achieve over a longer period ( longer than a week), usually over several days, weeks, or months Example: Client will raise right arm to shoulder height by Friday." Useful for clients who require health care for a short time and for those who are frustrated by long term goals that seem difficult to attain & satisfaction of achieving short term goals. Example: Client will regain full use of right arm in 6 weeks." Often used for clients living at home and have chronic health problems and for clients in rehab facilities, nursing homes, and extended care facilities.
Question #16-2: Define the 4 stages of pressure ulcers
Stage 1. (figure A) • A persistent area of skin redness (without a break in the skin) usually over a bony prominence with non-blanching or that does not disappear when pressure is relieved. ( may be inflamed, painful, and warm to touch) Stage 2. (figure B) • A partial thickness skin (epidermis, dermis or both) is lost. The ulcer is superficial and may appear as an abrasion, blister, or shallow crater. Redness or swollen and painful Stage 3. (figure C) • A full thickness of tissue is lost, exposing the subcutaneous tissues— • Slough (soft yellow or white tissue ) may be present • Presents as a deep crater with or without undermining adjacent tissue. Stage 4. (figure D) • A full thickness of skin and subcutaneous tissue are lost, exposing muscle, tendon or bone. • Slough (soft yellow or white tissue) or eschar (black or brown necrotic tissue) may be present on some parts of the wound. • Often includes undermining and tunneling.
18. What is objective and subjective data? What are the sources of data collection? 234
Subjective data: are your client's verbal descriptions of their health problems or health history. Only clients provide subjective data. Subjective data usually includes feeling, perceptions, and self report of symptoms. Objective data: are observations or measurements of a client health status. When you collect objective data, apply critical thinking intellectual standards (clear, precise and consistent) so that you can correctly interpret your findings. Examples: Inspection or condition of the wound, description of an observe behavior, and the measurements of vital signs. Sources of data collection Each source of data provides information about the client's level of wellness, anticipated prognosis, risk factors, health practices and goals, and patterns of health and illness. Sources of data are: Client: • Is the primary source. • A client is usually your best source of information • Client's who are conscious, alert, and able to answer questions correctly provide the most accurate information about their health care needs , lifestyle patterns, present and past illness, perception of symptoms, and changes in activities of daily living. Family and significant others: • They are primary sources of information FOR INFANTS or children , critical ill adults, and mentally handicapped, disoriented, or unconscious clients • They are also secondary sources. They confirm information that client provides. Whether a client takes medications regularly at home or how well the clients sleep Health care team • You frequently communicate with other health care team members in gathering information about your client • The information includes how the client is interacting within the health care environment, the client's reactions to treatment, and the result of diagnostic procedures or therapies... Medical records: The medical records are a source for: • the client's medical history • Laboratory and diagnostic test result • Current physical findings • The primary health care provider's treatment plan • The medical record is a valuable tool for checking the consistency and similarities of personal observation. • The client's records are confidential and protected by HIPPA (health Insurance portability and accountability act) Other records and the literature: • Educational, military, and employment records sometimes contain significant health care information (Ex: immunizations). • Reviewing nursing, medical, and pharmacological literature about client's illness completes your assessment database. Nurse's Experience: • Through the experience nurses learn to ask the right questions, choosing only the questions that will give the most useful information.
20. Define the Diagnostic Statement. What are the 3 components of the Diagnostic Statement? What part of the nursing care plan is originated from Part 1 and 2 of the nursing diagnostic statement? What are the defining characteristics of the NANDA nursing diagnoses? 253
The formal, written documentation of a nursing diagnosis. It includes Part I (diagnostic Phrase NANDA) , Linking word (R/T), and Part II( etiological phrase) 3 components of the Diagnostic Statement. Diagnostic Statement: Part 1 Linking word Part 2 Diagnostic Phrase (NANDA) related to (R/T) Etiological Phrase Why 1. Part I: (diagnostic label) is the name of the nursing diagnosis as approved by NANDA international. Human response (which are the biological ,psychological, social, and spiritual reactions to an event or a stressor such as disease or injury): naming and labeling the problem(actual or potential)It describes the essence of a client's response to health conditions in as few words as possible. Diagnostic labels include descriptors used to give additional meaning to the diagnosis. For example, the diagnosis impaired physical mobility includes the descriptor impaired to describe the nature or change in mobility that best describes the client's response. Example of descriptors include compromised, decreased, deficient, delayed, effective, imbalanced, impaired, and increased. 2.) Linking word: R/T related to 3.) Part II: Etiological phrase ( why the NANDA is a problem). Condition or etiology identified from the client's assessment data. It is associated with the client's actual or potential response to the health problem and can change by using nursing intervention. The etiological phrase is not a cause and effect statement; rather, it indicates that the etiology contributes to or is associated with the client's diagnosis. What part of the nursing care plan is originated from Part I and II of the nursing diagnostic statement? • Goals/Outcomes are originated from Part I • Interventions are originated from Part II What are the defining characteristics of the NANDA nursing diagnoses? • Manifestations, signs, and symptoms that cluster in patterns of related cues or inferences support the diagnostic judgment. Cluster and patterns of data often contain defining characteristics, the clinical criteria or assessment finding that supports an actual diagnosis.
3. Describe the types of wound drainage (exudate).1287
Type of Excudates (wound drainage ) • Serous - Clear watery plasma • Purulent -Thick yellow, green, tan, or brown ( present during infection ) • Sero-sanguineous- Pale, red, watery: mixture of clear and red fluid • Sanguineous - Bright red: Indicates active bleeding **
7. What are the lab values that identify an infection in the patient? 648
WBC Normal 5,000 - 10, 000 mm3. Increased in acute infection or decreased in certain viral or overwhelming infections. Erythrocyte Sedimentation Rate- Up to 15 mm/hr for men and 20 mm/hr for women. Elevated in presence of inflammatory process. **
What happens to the care plan if patient goals are not met?
o Reassess the client, determine accuracy of the nursing diagnosis, and establish new goals and expected outcomes, and select new interventions. An unmet goal reveals the client has not responded to interventions as planned. The nurse has to identify the factors that interfere with goal achievement. Usually a change in the client's condition, needs, or abilities makes alteration of the care plan necessary.
Evaluating:
• Measuring the degree to which goals / outcomes have been achieved and indentifying factors that positively or negatively influence goal achievement. Major actions: • Collaborate with client and collect data related to desire outcomes • Judge whether goals/outcomes have been achieve • Relate nursing actions to client outcomes • Make decisions about problem status • Review and modify the care of plan as indicated or terminate nursing care • Document achievement of outcomes and modifications of the care plan Purpose: • To determine whether to continue, modify or terminate the plan of care