NUR 323 exam 1

How would you know a nursing diagnosis is a nursing diagnosis (hint: what is not a nursing diagnosis)

-A medical diagnosis (type 1 diabetes) -A medical pathology (hypoglycemia) -Diagnostic tests, treatments, equipments (FBS, insulin, therapy, insulin pump) -Therapeutic patient need (needs to learn the relation among diet, exercise, and insulin) -A single sign or symptom (after successfully administering own insulin for 3 days, patient tells nurse "you give me my shot today") -An invalidated nursing inference (the above incident leads to nursing inference: noncompliance related to depression)

What makes a problem-focused nursing diagnosis different from a risk or health promotion diagnosis?

-A problem focused nursing diagnosis is a clinical judgement concerning an undesirable human response to a health condition/life process; exists in an individual; four components are label, definition, defining characteristics, and related factors -A risk nursing diagnosis is a clinical judgement concerning the vulnerability of an individual for developing an undesirable human response to health conditions/life processes -A health promotion a clinical judgement concerning motivation and desire to increase well being; actualize human health potential; responses expressed by an individual as readiness to enhance specific health behaviors

What criteria is used to determine interventions are well written?

-Assist the patient to meet specific outcomes that are related to be performed -Are dated when written and when the care plan is reviewed -Clearly and concisely describe the nursing action to be performed -Are signed by the nurse prescribing the other or intervention -Use only those abbreviations -Refer the nurse to the facility's procedure manual or other literature for the steps of routine, lengthy procedures -Well written outcomes define evaluative strategies

If given an evaluative statement, can you determine if it meets criteria?

-EX: Outcome met. Patient reports 1 week of no tobacco use -EX: Outcome partially met. Patient reports decreasing tobacco use from one pack per day to 4 to 6 cigarettes per day

Vision

-If a new person approaches or engages with your conversation, introduce him or her Touch the person's arm lightly when you speak so that he or she knows to whom you are speaking before you begin. -Face the person and speak directly to him or her. Use a normal tone of voice. Do not leave without saying that you are leaving. -If you are offering directions, be as specific as possible and point out obstacles in the path of travel. Use specifics such as "Left about twenty feet" or "Right two yards." -Use clock cues, such as "The door is at 10 o'clock." When you offer to assist someone with vision loss, allow the person to take your arm. -This will help you guide rather than propel or lead the person. -When offering seating, place the person's hand on the back or the arm of the seat. Alert people with low vision or blindness to posted information. -Never pet or otherwise distract a canine companion or service animal unless the owner has given you permission.

When are initial and focused assessments performed?

-Initial assessment is performed shortly after the patient is admitted to a health care facility or service -A focused assessment may be done during the initial assessment if the patient's health problems surface, but is routinely part of ongoing data collection

What will promote wound healing?

-Intact skin is the first line of defense -The body responds systematically to trauma, but adequate blood supply and nutrition are essential for effective healing -All foreign debris or material must be removed from wounds to promote healing -Surgical asepsis is used when providing wound care -An individual's overall health status and the extend of damage involved in the wound affects healing process

How is comprehensive baseline data used by the nurse?

-It enables nurse to make a judgement about a persons health status, ability to manage his or her own need for self care, and the need for nursing care -Plan and deliver thoughtful, person-centered nursing care that draws on the person's strengths and promotes optimum functioning, independence, and well-being -Refer the patient to a provider or other health care professional, if indicated

What guides a nurse in making those rankings?

-Maslow's hierarchy of human needs: basic needs of the patients must be met before the patient can focus on higher ones Physiologic needs, safety needs, love and belonging needs, self-esteem needs, and self-actualization needs -Patient preference: What patient thinks are most important First meet the needs that the patient thinks are most important, so long as this order of priority determined by the patient does not interfere with other vital therapies -Anticipation of future problems: Tap your knowledge base to consider effects of different nursing actions Assigning low priority to a diagnosis that the patient wants to ignore but can result in harmful future consequences for the patient might be nursing negligence

What information is used to develop each of the nursing diagnosis statements?

-Phrase the nursing diagnosis as a patient problem or alteration in health state rather than as a patient need -Check to make sure that the patient problem precedes the etiology and that the two are linked by the phrase

What are possible nursing Diagnoses and expected outcomes to drive nursing care?

-Receive respectful and culturally and age appropriate care -Be free from injury and adverse effects -Be free from infection and DVT -Maintain fluid and electrolyte balance; skin integrity, normal temperature -Have pain managed -Demonstrate understanding of physiologic and psychological responses to surgery -Participate in rehabilitation process

What type of data is considered objective?

-SIGNS -Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them -EXAMPLE: elevated temperature, skin moisture, vomiting -Data is obtained through physical examination

Lack of communication leads to failure of....

-Sharing information with the team -Requesting information from others -Directing information to specific team members -Including patients and their families in communication involving their care -Ineffective communication identified as root cause for nearly 66% of all reported sentinel events

If the postoperative complications were to occur, what assessment findings would you (the nurse) detect?

-Shift in vital signs (possible fever) -Dehydration -Coughing or trouble breathing

How does assessment findings for a Stage 1 pressure injury differ from a Stage 2 pressure injury?

-Stage 1 present as intact skin with nonblanchable redness of a localized area usually over a bony prominence; the area may be painful, slim, warmer, or cooler as compared to adjacent tissue -Stage 2 involves partial-thickness loss of dermis and presents as shallow, open wound or a ruptured/intact serum-filled blister

What are the two components of an evaluative statement?

-The decision about how well the outcome was met -The patient pertinent data or behaviors that support the decision

Examples of missed communication opportunities

-Unavailable or underutilized status board -Inconsistencies in the utilization of automated systems -Poor documentation (not timed, nonspecific, illegible, and incomplete) -Failure to seek input from the patient

What verbs should and should be used in an outcome statement?

-Verbs to use: Explain, Verbalize, Select, Apply, Prepare, List, Identify, describe, Design, Choose, and Demonstrate -Verbs to avoid: Know, Understand, Learn, and Become aware

Disability assessment questions to consider?

-What usual health status considerations might be needed? -What if any disability-related consideration are needed to seek care or needed during an examination? -Is there any risk of abuse or is abuse detected? -Is the patient experiencing depression? -How and what impact does aging have related to disability? -Is the patient at risk for or have any secondary health conditions? -Are there any accommodations required in the home for self-care? -What is the patients cognitive status for discussion and conversation; are there any specific strategies needed for communication (verbal or nonverbal)? - Are there any nursing care modifications required? -Are there any specific accommodation, strategies, or modifications required during patient education? -What health promotion and disease prevention strategies require implementation? -What is the extent of independence vs. dependance? -Are there any barriers to care, services related to insurance coverage?

Correlated risk factors with prevention measures

1.) Hypertension (high blood pressure)= watch high fat foods and high sodium intake 2.) Tobacco use (any form of tobacco use) and exposure to secondhand smoke= stop use of tobacco 3.) Overweight or obesity (high BMI)= eat healthier food options and exercise daily 4.) Lack of physical activity= can lead to obesity 5.) Excessive alcohol use= can make issues with liver and can lead to addiction 6.) Consumption of diets low in fruits and vegetables= eat more fruits and vegetables for fiber and vitamin intake 7.) Consumption of food high in sodium and saturated fats= lower intake of those foods as they can lead to hypertension and obesity issues

Two considerations in communication are.....

1.) Whom you are communicating with= The audience will influence how information is conveyed; For example, an information exchange with a lab technician may differ from an exchange with a physician 2.) How you communicate= Includes verbal (see standards for effective communication) and nonverbal (in healthcare most is written, but nonverbal influences)

What is implementing a care plan mean?

Carrying out plan evidence-based nursing actions by determining patient's new or continuing need for nursing assistance , promoting self care, and assisting patient to achieve valued health outcomes

Using inspection and palpation, what findings related to the wound would be assessed?

Infection, Hemorrhage, dehiscence and evisceration ( most serious; partial or total separation of wound), fistula (abnormal passage from an internal organ or vessel to the outside of the body)

What make a 3-part nursing diagnosis differ from a 2-part?

-A 2-part statement lists the patients problem and its cause -A 3-part statement lists the patients problems, its cause, and the problems defining characteristic

What interventions are used to prevent pressure injury?

-A pressure injury is localized injury to the skin and/or underlying tissue usually over a bony prominence or related to a medical or other device -Most pressure injuries develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time -Compressed blood vessels can develop pressure injuries -Friction caused by patients lifting and moving themselves in bed with use of arms and feets or when patients are pulled or slid over sheets causing friction burns -Patients who are pulled, rather than lifted, when being moved are at risk for injuring from shearing forces as well as patients who are partially sitting up in bed

One critical result of effective communication is....

-A shared understanding between the sender and receiver of the information conveyed

How might wounds be described or classified?

-A wound is a break or disruption in the normal integrity of the skin and tissues -Wounds occur with skin is no longer able to function as a barrier and protective function is impaired -Wounds are classified by how wounds are acquired (intentional which is purposefully created for therapeutic purposes like in surgery; risk for infection is decreased or unintentional which could be accidental from an unexpected trauma; risk for infection is increased) and extent of exposed skin structure/follows normal healing time (open occurs from intentional or unintentional; closed results from a blow, force and strain caused by trauma and skin surface is not broken but soft tissue is damaged; acute wounds usually result from surgical incisions but risk of infection is low; chronic wounds remain in the inflammatory phase of healing and do not progress os risk of infection is higher

Challenges associated with chronic illness and providing care to those living with chronic illness/disability

-Alleviate and manage symptoms -Psychologically adjust to and physically accommodate resulting disability -Prevent and manage crises and complications -Carry out regimens as prescribed -Validate individual self-worth and family functioning -Manage threats to identity -Normalize personal and family life as much as possible -Live with altered time, social isolation, and loneliness -Establish networks of support and resources that can enhance quality of life -Return to a satisfactory way of life after an acute debilitating episode (ex: myocardial infarction or stroke) or reactivation of a chronic condition -Die with dignity and comofort

What part of the nursing diagnosis is an expected outcome derived?

-An expected outcome is an expected conclusion to a patient health problem or patient's health expectation with specific measurable criteria; the results achieved -Outcomes can be short or long-term, with long-term generally established with more than a week time frame -When identifying outcomes, remember that nurses nurse people not problems so every outcome you write should support the overall treatment plan and "make sense" in terms of the overall goals for the patient

Cognitive

-Be alert to the individual's responses so that you can adjust your method of communication as necessary. For example, some people may benefit from simple, direct sentences or from supplementary visual forms of communication, such as gestures, diagrams, or demonstrations. -Use concrete rather than abstract language. Be specific, without being too simplistic. When possible, use words that relate to things you both can see. Avoid using directional terms such as right, left, east, or west. Be prepared to give the person the same information more than once in different ways. -When asking questions, phrase them to elicit accurate information. People with intellectual/cognitive disabilities may be eager to please and may tell you what they think you want to hear. Verify responses by repeating the question in a different way. -Give exact instructions. For example, "Be back for lab work at 4:30," not "Be back in 15 minutes." -Avoid giving too many directions at one time, which may be confusing. -Keep in mind that the person may prefer information provided in written or verbal form. -Ask the person how you can best relay the information. -Using humor is fine, but do not interpret a lack of response as rudeness. Some people may not grasp subtleties of language. -Know that people with brain injuries may have short-term memory deficits and may repeat themselves or require information to be repeated. -Recognize that people with auditory perceptual problems may need to have directions repeated and may take notes to help them remember directions or the sequence of tasks. They may benefit from watching a task demonstrated. -Understand that people with perceptual or "sensory overload" problems may become disoriented or confused if there is too much to absorb at once. Provide information gradually and clearly. Reduce background noise if possible. -Repeat information using different wording or a different communication approach if necessary. Allow time for the information to be fully understood. -Do not pretend to understand if you do not. Ask the person to repeat what was said. Be patient, flexible, and supportive. -Be aware that some people who have an intellectual disability are easily distracted. Try not to interpret distraction as rudeness. -Do not expect all people to be able to read well. Some people may not read at all.

Speech

-Be friendly; start up a conversation. -Be patient; it may take the person a while to answer. Allow extra time for communication. -Do not speak for the person. -Give the person your undivided attention. -Ask the person for help in communicating with him or her. If the person uses a communication device such as a manual or electronic communication board, ask the person the best way to use it. -Speak in your regular tone of voice. -Tell the person if you do not understand what he or she is trying to say. -Ask the person to repeat the message, spell it, tell you in a different way, or write it down. Use hand gestures and notes. -Repeat what you understand. The person's reactions will clue you in and guide you to understanding. -To obtain information quickly, ask short questions that require brief answers or a head nod. Avoid insulting the person's intelligence with oversimplification. -Keep your manner encouraging rather than correcting.

What are the different types of postoperative complications (immediately, within 24-48 hours)?

-Cardiovascular → Hemorrhage (excessive internal or external blood loss; usually seen with hypotension, weka, thready, rapid pulse, decreased urine output, disorientation, cold and clammy skin, and rapid respirations); Shock (establish and maintain airway, place patient in shock position which is flat on back with legs elevated at 20 degree angle and knees straight); Thrombophlebitis (implement leg exercises in bed every 2 hours, assist with ambulations, possibly apply pneumatic compression devices, assess for leg swelling); To prevent cardiovascular complications in general try keeping patient warm following surgery and assess vital signs, provide cover, maintain fluid balance, etc. -Respiratory → Pulmonary embolism (Piece of thrombus that has traveled to another location in body lodges in pulmonary vessels; signs can be dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, and anxiety); Atelectasis (incomplete expansion or collapse of alveoli with retained mucus so there is poor gas exchange; SIgns include decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, apprehension, and slight increase in temperature; primary care is to ensure oxygenation of tissues); Pneumonia (an inflammation of alveoli as the result of an infectious process or presence of foreign material; Signs include aspiration, infection, depressed cough reflex, increased secretions from anesthesia, dehydration, and immobilization; Primary care is to treat underlying infection, maintain respiratory function, and prevent the spread); To prevent respiratory complications monitor vital signs, implement deep breathing, coughing, incentive spirometry, turning in bed every 2 hours, ambulating, maintaining hydration, avoid positioning that decreases ventilation, and monitor responses to narcotic analgesics -Surgical site infection → To prevent assess vital signs for fever, maintain hydration, maintain nutritional status, encourage a diet high in proteins, carbohydrates, calories, and vitamins, using proper hand hygiene, follow aseptic technique when changing dressing, and dispose of soiled gloves and dressings according to protocol

What is evaluated when an outcome is cognitive, psychomotor, affective, or physiologic?

-Cognitive → describes increases in patient knowledge or intellectual behaviors -Psychomotor → describe the patients achievement of new skills -Affective → describe changes in patient values, beliefs, and attitudes -Physiologic → describe changes in patient physiologic parameter

What would be the focus of a cognitive, psychomotor, affective, clinical, functional and quality of life based outcome?

-Cognitive → outcomes describe increases in patient knowledge or intellectual behaviors -Psychomotor → Outcomes describe the patients achievement of new skills -Affective → Outcomes describe changes in patient values, beliefs, and attitudes -Clinical → Describe the expected status of health issues at certain points in time, after treatment is complete; addresses whether the problems are resolved or to what degree -Functional → Describe the person's ability to function in relation to the desired usual activities -Quality of life → Focus on key factors that affect someone's ability to enjoy life and achieve personal goals

Describe how communication affects team processes and outcomes

-Communication (a lifeline of the team) affects team processes and team outcomes by influencing how the team functions and as well as the flow of the mechanism of teamwork resulting in an impact on patient safety by increasing the risk of error -Communication facilitates the development of shared mental models, adaptability, mutual trust, and patient safety

Define effective communication

-Complete= includes all relevant information; communicate all relevant information while avoiding unnecessary details that may lead to confusion; leave enough time for patient questions and answer all questions completely -Clear= layman's terms with patients, standard professional language with team; use information that is plainly understood; use common terminology when communicating with members of the team -Brief= concisely communicated -Timely= be dependable without delay; be dependable about offering and requesting information; avoid delays in relaying information that could compromise a patient's situation; note times of observations and interventions in patient's record; update patients and families frequently

What makes a "cue" differ from an "inference"?

-Cues: Subjective data to help identify that something may be wrong -Inferences: Judgements reached about cues; inferences must be validated

What factors are used in choosing a nursing diagnosis?

-Desired patient outcomes -Characteristics of the nursing diagnosis -Research base for the intervention -Feasibility for doing the intervention -Acceptability to the patient -Capability of the nurse

How do direct and indirect care interventions differ?

-Direct care → a treatment performed through interaction with the patients; physiologic (physical contact) and psychological (supportive and counseling) -Indirect care → a treatment performed away from the patient but on behalf of a patient; aimed to environment management, collaboration with team, and support for direct interventions

What is the purpose of a care plan?

-Directs the efforts of the nursing team working with the patient to meet his or her health goals -Ensures the nursing team delivers efficient, holistic, goal-oriented, person-centered care to patients

General approach to use

-Do not be afraid to make a mistake when interacting and communicating with someone with a disability or chronic medical condition. -Keep in mind that a person with a disability is a person first and is entitled to the dignity, consideration, respect, and rights you expect for yourself. -Treat adults as adults. Address people with disabilities by their first names only if extending the same familiarity to all others present. Never patronize people by patting them on the head or the shoulder. -Relax. If you do not know what to do, allow the person who has a disability to identify how you may be of assistance and to put you at ease. If you offer assistance and the person declines, do not insist. If your offer is accepted, ask how you can best help, and follow directions. -Do not take over. If someone with a disability is accompanied by another individual, address the person with a disability directly rather than speaking through the accompanying companion. -Be considerate of the extra time it might take for a person with a disability to get things done or said. Let the person set the pace. -Do not be embarrassed to use common expressions, such as "See you later" or "Got to be running," that seem to relate to the person's disability. -Use people-first language: Refer to "a person with a disability" rather than "a disabled person" and avoid referring to people by the disability or disorder they have (e.g., "the diabetic").

Mobility

-Do not push a person's wheelchair or grab the arm of someone walking with difficulty without first asking whether you can be of assistance and how you can assist. Personal space includes a person's wheelchair, scooter, crutches, walker, cane, or other mobility aid. Never move someone's wheelchair, scooter, crutches, walker, cane, or other mobility aid without permission. -When speaking for more than a few minutes to a person who is seated in a wheelchair, try to find a seat for yourself so that the two of you are at eye level. -When giving directions to people with mobility limitations, consider distance, weather conditions, and physical obstacles such as stairs, curbs, and steep hills. -Shake hands when introduced to a person with a disability. -People who have limited hand use or who wear an artificial limb do shake hands.

How is data interpreted and analyzed by the nurse to make the best determination of a nursing diagnosis?

-Experienced nurses will begin interpreting and analyzing data as it is collected -Significant data should raise a red flag for the nurse who then will look for patterns or clusters of data that signal an actual or possible nursing diagnosis

What are 3 common errors to avoid when writing an outcome statement?

-Expressing the patient outcome as a nursing intervention: "Mr.Meyer will drink 60-mL fluid every 2 hours while awake beginning 2/25/21" -Using verbs that are not observable and measurable: "After attending infant care class, Mrs.Gaston will correctly demonstrate the procedure for bathing her newborn" -Including more than one patient behavior/manifestation outcomes: "By next meeting, patient will identify 3 dangers of smoking" -Writing outcomes that are so vague that other nurses are unsure of the goal for nursing care: "After teaching, patient will describe 2 new coping strategies to try"

If the postoperative complications were to occur, what actions should the nurse take or how should the nurse respond? (keep in mind what is done first or what action(s) would be of greatest/highest priority)

-First step is to notify physician and medical intervention team is intervention is needed immediately -Then continue to keep hydration and check urine output -Continue to check vital signs and notify if any shift is noticed -Administer oxygen or medications if needed Keep ventilation open

What criteria are used to determine data validity?

-Gathered focused information to support, confirm, or negate suspicions -Data is validated when the data lacks objectivity, suspicions are not objective

What are the different types of anesthesia that might be experienced during a surgical procedure and why would one type be used over another?

-General → Administration of drugs by inhalation or intravenous route (CNS depression); can be used for patients of any age, surgical procedure, and patient is totally unaware of the physical trauma of the surgery; its effects can cause circulatory and respiratory depression, is often associated with postoperative nausea and vomiting, alterations in thermoregulation during and after surgical procedure, and postoperative bronchospasm can occur -Moderate sedation/analgesia → Used for short-term, minimally invasive procedures; involves IV administration; patient able to keep open own airway; reduces anxiety, decreases discomfort/pain associated with the procedure, and provides some degree of amnesia -Regional → Anesthetic agent injected near a nerve or nerve pathway or around operative site; does not cause narcosis (sleepiness) but can result in analgesia (loss of sensory function) and reflex loss (motor function); nerve blocks is an injection around nerve trunk, spinal anesthesia is injection into the subarachnoid space, and epidural anesthesia is an injection through intervertebral spaces -Topical and local anesthesia → Used on mucous membranes, open skin, wounds and burns; targets a specific tissue of the body

What are the 3 rankings when a nurse is prioritizing a list of nursing diagnoses?

-HIGH (greatest threat to health/well-being) -MEDIUM (not life threatening) -LOW (not specifically related to current health/well-being)

What are the principles & phases of wound healing?

-Hemostasis → The process of the wound being closed by clotting. Hemostasis starts when blood leaks our of the body, blood vessels constrict to restrict blood flow, platelets stick together to seal the break in the wall of the blood vessel and coagulation occurs and reinforces the platelet plug with threads of fibrin which are like a molecular binding agent; The hemostasis stage of wound healing happens very quickly -Inflammatory → Begins after the injury when transudate leaks from blood vessels causing localized swelling. During the inflammatory phase, damaged cells, pathogens, and bacteria are removed from the wound area where cellular metabolic substances create the swelling, heat, pain, and redness commonly seen; Inflammation is only problematic is prolonged or excessive -Proliferative or reconstructive → Rebuilding with new tissue (granulation). A new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient oxygen and nutrients. Epithelization happens faster when wounds are kept moist and hydrated -Maturation and remodeling → When collagen is remodeled the wound fully closes. During the maturation phase, collagen fibers lie closer together and cross link, reducing scar thickness and making skin around wound stronger

Hearing

-If you are speaking through a sign language interpreter, remember that the interpreter may lag a few words behind—especially if there are names or technical terms to be finger spelled—so pause occasionally to allow the interpreter time to translate completely and accurately. -Talk directly to the person who has hearing loss, not to the interpreter. However, although it may seem awkward to you, the person who has hearing loss will look at the interpreter and may not make eye contact with you during the conversation. -Before you start to speak, make sure that you have the attention of the person you are addressing. A wave, a light touch on the arm or the shoulder, or other visual or tactile signals are appropriate ways of getting the person's attention. -Speak in a clear, expressive manner. Do not over enunciate or exaggerate words. -Unless you are specifically requested to do so, do not raise your voice. Speak in a normal tone; do not shout. -To facilitate lip reading, face the person and keep your hands and other objects away from your mouth. Maintain eye contact. Do not turn your back or walk around while talking. If you look away, the person might assume that the conversation is over. -Avoid talking while you are writing a message for someone with hearing loss, because the person cannot read your note and your lips at the same time. -Try to eliminate background noise. Encourage feedback to assess clear understanding. -If you do not understand something that is said, ask the person to repeat it or to write it down. The goal is communication; do not pretend to understand if you do not. -If you know any sign language, try using it. It may help you communicate, and it will at least demonstrate your interest in communicating and your willingness to try.

What problems might a nurse encounter in data collection?

-Inappropriate organizations of information -Omission of pertinent data -Inclusion, irrelevant, erroneous or misinterpreted data -Failure to establish rapport and partnership with patient -Recording an "interpretation" of data rather than observed behavior -Failure to update the database

What assessments does the nurse need to complete prior to a person having surgery? (includes items listed on pre-op checklist, consent (responsibilities), etc.)

-Informed consent to ensure the patient's understanding of the procedure/treatment prior to giving consent -List routinely taken medications and ask the provider which is taken or omitted -Notify the surgeons office if a cold or infection develops before the surgery -List all allergies, and be sure to inform the OR staff -Follow all surgeon instructions regarding bathing or showering (use of soap solution) remove nail polish and do not wear makeup, lotions, or deodorant on the day of procedure -Leave all jewelry and valuables at home -Wear clothing that buttons in front; short-sleeved garments for hand surgery -Must have someone available for transportation home afterwards -Inform about limitations (specific time) on eating and drinking before surgery -Notify when and where ti arrive for the procedure with estimated time for procedure

What makes an initial different from a focused assessed?

-Initial assessment is performed shortly after the patient is admitted to a health care facility or service; the purpose of this assessment is to establish a complete database for problem identification and care planning; the nurse collects data concerning all aspects of the patients priorities for ongoing focused assessments and creating a reference baseline for future comparison -Focused assessment is when the nurse gathers data about a specific problem that has already been identified; a focused assessment may be done during the initial assessment if the patient's health problems surface, but is routinely part of ongoing data collection

Identify communication challenges

-Language barrier -Distractions -Physical proximity -Personalities -Workload -Varying communication styles -Conflict -Lack of information verification -Shift change

How do nurse initiated, physician/provider initiated and collaborative interventions differ from each other?

-Nurse initiated → actions performed by a nurse without a physicians order; independent nursing actions; when selecting nursing interventions, the nurse specifically addresses factors that cause or contribute to the patients problems: Some examples are monitoring patient health status and response to treatment, reduce risks, resolve and prevent and manage a problem, promote independence with activities of daily living, promote optimum sense of physical and psychological and spiritual well-being, and give patients the information they need to make informed decisions and be independent -Physician/provider-initiated → Actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctors order; collaborative nursing actions; the physician and nurse are legally responsible for these interventions safely and effectively -Collaborative → Treatments initiated by other providers such as pharmacists, respiratory therapists, or physician assistants but carried carry out by the nurse

What guidelines are used in the selection of a nursing diagnosis?

-Nursing interventions should be... -Valued, whenever possible, by the patient and family -Appropriate in terms of the nursing diagnosis and related patient outcomes, safe, and efficient -Consistent with research findings and standards of care -Realistic in terms of abilities, time, and resources available to the nurse and patient -Compatible with the patients values, beliefs, and cultural and psychosocial background -Compatible with other planned therapies

What nursing actions should be implemented to prevent the occurrence of post-operative complications? (interventions/actions are also inclusive of patient teaching)

-Obtaining a health history and performing a physical assessment to develop a baseline database -Identifying risk factors and allergies that could cause surgical adverse events -Identifying medications and treatments the patient is currently receiving -Determining the teaching and psychosocial needs of the patient and family -Determining post surgical support and referral needs for recovery

Mental health

-Offer to shake hands when introduced. Use the same good manners in interacting with a person who has a psychiatric/mental health disability that you would with anyone else. -Make eye contact and be aware of your own body language. Like others, people with psychiatric/mental health disabilities will sense your discomfort. -Listen attentively, and wait for the person to finish speaking. If needed, clarify what the person has said. Never pretend to understand. -Treat adults as adults. Do not patronize, condescend, or threaten. Do not make decisions for the person or assume that you know the person's preferences. -Do not give unsolicited advice or assistance. Do not panic or summon an ambulance or the police if a person appears to be experiencing a mental health crisis. Calmly ask the person how you can help. -Do not blame the person. A person with a psychiatric disability has a complex, biomedical condition that is sometimes difficult to control. The person cannot just "shape up." It is rude, insensitive, and ineffective to tell or expect a person to do so. -Question the accuracy of media stereotypes of psychiatric/mental health disabilities: Movies and media often sensationalize psychiatric/mental health disabilities. Most people never experience symptoms that include violent behavior. -Relax. Be yourself. Do not be embarrassed if you happen to use common expressions that seem to relate to a psychiatric/mental health disability. -Recognize that beneath the symptoms and behaviors of psychiatric disabilities is a person who has many of the same wants, needs, dreams, and desires as anyone else. If you are afraid, learn more about psychiatric/mental health disabilities.

How do the physiologic changes of aging pose risks to the older adult during the intra and postoperative phases of the surgical experience?

-Older patients have less physiologic reserve than younger patients -SKIN → ability to perspire decreases which leads to dry itchy skin that can become fragile and easily abraded -SQ FAT → a decrease in subcutaneous fat makes older adults more susceptible to temperature changes

What are the 3 perioperative phases of care?

-Preoperative → Begins with decision to have surgery, lasts until patient is transferred to operating room or procedural bed -Intraoperative → Begins when the patient is transferred to the OR bed until transfer to the post anesthesia until (PACU) -Postoperative → Lasts from admission to the PACU or other recovery area to complete recovery from surgery and last follow-up health care provider visit

What impedes wound healing?

-Pressure → Disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing -Desiccation → The process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound sire and delays healing -Maceration → The softening and breakdown of skin, results from prolonged exposure to moisture -Trauma → Results in delayed healing or the inability to heal -Edema → At a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue -Infection → Bacteria in a wound and increases stress on the body, requiring increased energy to deal with invaders -Excessive bleeding → Results in large clots Necrosis → Dead tissue present in the wound delays healing -Bioflim → The result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins -Personal hygiene → Hygiene has an impact on the health of skin in its ability to protect

How is first intention healing different from second and third intention wound healing?

-Primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges -Secondary intention have edges that are not well approximated. Large, open wounds such as burns or major trauma which require more tissue replacement and are often contaminated, commonly healed by secondary intention. This type of healing is typically what occurs with some pressure injury wounds or when someone experiences an abrasion/scrape

Differentiate characteristics of chronic illness/disease

-Psychological and social issues -Phases of illness -Therapeutic regimens -Managing a chronic illness -Development of other chronic conditions -Family life -Home life -Self-management -Collaborative process -Health care costs -Lost income -Ethical issues -Living with uncertainty

What are the key elements of a well-written care plan?

-Represents an effectively philosophy of nursing and advances nursing's four aims: promoting health, preventing disease and illness, promoting recovery, and facilitating coping with altered functioning -Is prepared by the nurse who best knows the patient and is recorded on the day the patient presents for treatment and care, according to facility policy, with modifications to the initial plan signed and dated is responsive to the individual characteristics, values and needs of the patient, and is culturally appropriate -Clearly identifies the nursing assistance the patient needs and nursing collaborative responsibilities for fulfilling the medical and interdisciplinary care plan (clearly specifies nursing diagnoses/problems, patient outcomes, nursing interventions, and evaluate strategies) -Directs the nurse's assessment priorities, caregiving behaviors, and teaching, counseling, and advocacy behaviors is based on scientific principles and incorporates findings of nursing research -Meets the developmental, psychosocial, and spiritual needs of the patient as well as the patient's physiological needs is updated to reflect changes in the patient's status and related needs for nursing care -Addresses the discharge needs of the patient and families -Provides for as much patient and family participation as possible -When appropriate, is compatible with the medical care plan and that of the interdisciplinary team -Creates a record that can be used for evaluation, research, reimbursement, and legal purposes

Differentiate TeamSTEPPS tools/strategies (SBAR and checkback) that can improve team's communication

-SBAR= Situation (what is going on with the patient), Background (what is the clinical background or context), Assessment (what do I think the problem is), and Recommendation (what would I I recommend) -Checkback= A closed-loop communication strategy used to verify and validate information exchanged; Involves the sender initiating, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received

What type of data is considered subjective?

-SYMPTOMS -Information perceived only by the affected person -EXAMPLE: pain experience, dizziness, feeling anxious -Data obtained through patient interview

What strategies does the nurse use to prevent pressure injuries?

-Skin assessment → can use the braden skin risk tool assessment -Skin care → use pH balanced cleansers, clean skin promptly after episodes of incontinence, use skin moisturizers on dry skin, and avoid positioning on an area of erythema, pressure injury -Nutrition → Valid and reliable risk of malnutrition screening tool, refer to nutritionalist/registered dietician if screen positive for malnutrition, be present and assist at mealtimes, encourage fluids and balance diet, and provide nutritional supplements if needed -Repositioning and mobilization → turn and reposition if at risk, frequency is based on support surface, skin tolerance to pressure, and individual preferences, turn into a 30 degree side lying position, palpate scrum to be sure off bed, avoid pressure points including heels off bed, and use breathable incontinence pads -Education → Instruct teach back about pressure injury, instruct with patient and family with using and applying reduction interventions

How is a Stage 3 pressure injury different from a Stage 4 pressure ulcer/injury?

-Stage 3 is defined as a full-thickness loss of skin present with adipose in ulcer, granulation tissue, epibole, and slough or eschar areas of the wound -Stage 4 is defined as full thickness skin and tissue loss with a palpable bone, fascia, muscle, tendon, or ligament exposed, and slough or eschar might be present

What criteria is used by the nurse to terminate, modify or continue a plan of care?

-Terminate the care plan when each expected outcome is achieved (the nursing diagnosis/problem has been resolved)- outcome met -Modify the care plan if there are difficulties achieving the outcomes- outcomes not met -Continue the care plan if more time is needed to achieve the outcomes- outcome partially met

Where does the nurse obtain patient data?

-The nursing history and physical examination are the primary components of data collection -The patient should always be considered the primary source and best source of information

How would you define each component of an outcome statement?

-The purpose is to design a plan of care with and for the patient -The care plan facilitates the following results once implemented: prevention, reduction, or resolution of patient health problems; the attainment of the patients health expectations

What is the purpose an initial and focused assessment?

-The purpose of this assessment is to establish a complete database for problem identification and care planning -A focused assessment may be done during the initial assessment if the patient's health problems surface, but is routinely part of ongoing data collection; another purpose is to identify new or overlooked problems

Why must data be validated and if not validated, how might that influence how care is provided?

-The purpose of validating data during data collection is to keep data as free form error, bias, and misinterpretation as possible -Invalid information can lead to inappropriate nursing care

How are surgical procedures classified?

-Urgent → elective (preplanned and based on the patients choice and availability of scheduling for the patient, surgeon, and facility. This is a nonurgent procedure that does not have to be done immediately), urgent (must be done within a reasonably short time frame to preserve health but is not an emergency), emergency (must be done immediately to preserve life, a body part, or function) -Risk → major (surgical procedure is high risk, involves body organs or the situation is life threatening and high risk for postoperative complications; requires hospitalizations and specialized care) or minor (surgical procedure is low risk with few complications) -Purpose → diagnostic (confirm a diagnosis), ablative (remove diseased body part), palliative (relieve or reduce the intensity of illness; not curative), reconstructions (restore function to traumatized or malfunctioning tissue; improve self concept), transplantation (replace diseased/malfunctioning organs or structures), and constructive (restore function in congenital anomaly)

What are the key principles associated with completing a wound dressing change?

-Use standard precautions -Moisten a sterile gauze pad or swab with the prescribed agent -Clean from top to bottom -Work outward from incision in lines parallel to it -Wipe from clean area toward less clean area -The purpose of wound dressings are to provide physical, psychological, and aesthetic comfort; to remove necrotic tissue; to prevent, eliminate, or control infection; to absorb drainage; maintain a moist environment; to protect wound from further injury; and to protect surrounding wound

What preoperative assessment information do you need to prepare the older adult for a surgical experience?

-When preparing, establish a therapeutic relationship and allow patient to verbalize fears and concerns, use active listening skills to identify anxiety and fear, use touch to demonstrate genuine empathy and caring, be prepared to respond to common patient questions about surgery, -Explain how the surgery and postanesthesia care will last and what will be done before, during, and after surgery -Give a description of the healthcare team members part of their surgical experience -Where and when to report for admission -Instructions for preoperative skin preparation, fasting, bowel prep -Instructions for taking any special medication -The importance of bringing an adult to drive patient home if needed -Explanation of any sensory alterations they may experience during the preoperative period -Explain what to expect in the OR -Teach the patient and family about any medication to relieve pain that may be given after

What is chronic illness?

A noncommunicable disease not passed from person to person and generally slow progressing

What component of the nursing diagnosis are nursing interventions derived?

Any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes

What are the suggested components with their purpose in a nursing student care plan?

Assessment/diagnosis, goal/outcome, nursing interventions, scientific rationale, and evaluation

What is the purpose of nursing interventions?

Nursing interventions are selected and developed on information that relates to the cause (etiology) of the problem, the factors that are maintaining the unhealthy state or response

How might assessment data be organized? (hint: models of organizing or clustering data)

Organized into clusters

What makes a data cluster different from a pattern of data?

Organizing data is clustering data

What are the components of a nursing intervention statement?

Statements about achievement of the desired outcome (met, partially met, not met) and lists actual patient behavior as evidence supporting the statement

Which of the assessments provides the nurse comprehensive baseline data?

The initial comprehensive assessment results in a baseline data

What nursing care activities are performed pre and postoperative (includes assessment, nursing care activities which includes patient teaching)?

The primary goals for care include activities to meet elimination, fluid and electrolyte balance, nutrition, rest and comfort, and pain management needs

What is the purpose of a nursing diagnosis?

The purpose of diagnosis is to clarify the exact nature of the problems and risks that must be addressed to achieve the overall expected outcomes of care

What is the purpose of the evaluation step?

To allow the patient's achievement of expected outcomes to direct future-nurse patient interactions