Term
| Criteria for Nursing Profession |
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Definition
1. extended education 2 or 4 years
2. well defined body of knowledge
3.stong service orientation
4.professional organizations that set standards
5.code of ethics
6.autonomy in decision making
7.research- evidence based practice |
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Term
| purpose of the code of ethics |
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Definition
| to define the primary goals and values of the profession, to set a moral code and standard |
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Term
| define evidence based practice and its importance in nursing |
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Definition
integrating the best research evidence with clinical expertise and patient values.
it is important to understand why you do what you do, to make informed care decisions. |
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Term
| common elements in the Nurse practice acts and licensure laws |
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Definition
1. create state BON
2.establish criteria for education and licensure
3.define legal requirements for RN, LPN |
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Term
| purpose of standards of professional performance |
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Definition
to define competent levels of behavior encompassing quality of practice (providing quality patient care) professional practice evaluation (seeking constructive feedback) education (seeking new exeperiences and practicing of skills)
collegiality (sharing knowledge and assisiting peers) ethics (maintain HIPAA, act as an advocate) collaboration (including patient, family, health care providers) research (use best available research to make patient care plans) resource utilization (helping patient find additional resource to meet needs {social worker}) leadership (team player, directing cargiving among all caregivers) |
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Term
| purpose of standards of practice |
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Definition
| define nurse activities unique to nursing for the benefit of the patient |
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Term
| components of critical thinking |
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Definition
using scientific method to examine all elements of a situation
make judgements based on fact
think through strategies
devising multiple scenarios
determine numerous possible outcomes |
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Term
| steps of the nursing process |
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Definition
5 steps
1. assess-collect information, current complaint, current situation, observation as well as interview
2. nursing diagnosis- deine and label the situation, nanda label+cause+data that substantiates
3. planning- identify goals (desired change) and expected outcomes (measurable "shown by") and nursing interventions (actions to be taken by the nurse)
4.implementation- educate, medicate etc.
5.evaluation- does the patient show a change, have the outsomes been met? |
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Term
| Patient benefits of nursing process |
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Definition
recipient of quality care
patient can participate and collaborate
continuity of care given among all nurses |
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Term
| nurse benefits of nursing process |
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Definition
organized nursing care
deliver quality care
ensure consistency
gives a nursing language |
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Term
| what comprises a diagnostic statement |
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Definition
actual problem (nanda label)
etiology (cause of problem)
S/s (data that substantiates) |
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Term
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Definition
to define, refine, and promote terminology that accurately reflects nurses; critical judgements.
(create nursing diagnosis labels) |
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Term
| charachteristics of a nursing diagnosis |
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Definition
clinical judgement about responses to actual or potential health problems
refers to conditions nurses are licensed to treat
oriented toward individual
changes as the patients condition changes |
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Term
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Definition
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Term
| goal of nursing intervention |
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Definition
desired change in patient behavior.
"will have nausea under control 24 hours post op" |
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Term
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Definition
realistic patient behaviors that are measurable and aimed at meeting the goal
"will control nausea by requesting meds at first sign of nausea"
"will control nausea by only taking smlall sips of water" |
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Term
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Definition
actions taken by the nurse to achieve the outcomes.
"will explain the best positions to avoid nauseated stomach"
"will educate dietary aversions to prevent nausea"
"will provide anti-emetics" |
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Term
| puropse of boundaries in nurse-patient relationship |
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Definition
defines a safe area for nursing interactions
balances nurse power and patient vulnerability |
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Term
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Definition
theraputic:
letting a patient borrow a book, accepting a written card |
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Term
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Definition
nurse metting own needs, not the patients
imply harm
sexual misconduct
gossiping about coworkers
money exchange
many more! |
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Term
| therapeutic benefits of bedrest |
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Definition
reduce pain and need for pain medication
promote healing by decreasing need for oxygenation
restore equilibrium by providing rest
prevent toxin migration |
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Term
| 2 nursing goals promoting patient mobility |
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Definition
there are many but 2 examples could be
1. learning to use assistive devices (cane/walker/wheelchair/crutches)
2.relieve pain affecting mobility |
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Term
| effects of immobility on integument |
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Definition
pressure sores due to prolonged ischemia, prevented by turning q2h, maintaining proper hygiene
2. skin turgor loss (fluid loss) also turn q2h and provide proper hydration/nutrition |
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Term
| musculoskeletal complications from prolonged immobility and prevantative measures |
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Definition
atrophy, loss of muscle mass
decreased muscle strength, 3% a day
osteoporosis
contractures
preventative measures:
range of motion and physical therapy, proper positioning and alignment, pain control, assistive devies, proper nutrition. |
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Term
cardiovascular complications 1
due to reduced venous return |
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Definition
| resting workload on heart is greater reduced venous return also causes orthostatic hypotension since the venous return mechanism has become dormant, BP drops when sitting or standing. |
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Term
| reduced venous return/ orthostatic hypotension interventions |
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Definition
| rest patient in fowlers 5 min, dangle 5 min, stand and asses S/S and vitals return to bed if dyspnea, fatigue, chest pain etc. |
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Term
Cardiovascular complications 2
Due to venous stasis, increased blood coagulability and damage to vein wall intima |
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Definition
| thrombosis formation, deep vein thrombosis is typical in calf. |
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Term
| preventing thrombosis nursing interventions |
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Definition
| do not bend knee sharply for prolonged periods of time, proper body alignmnet frevents intima damage, no restirictive clothing, promote leg excercises, encourage fluids. |
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Term
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Definition
pain and pallor in exremities : esp. calf
erythyma
warmth
swelling |
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Term
| preventing thrombosis medically |
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Definition
heparin injections
lovenox injections
TED hose
sequential compression device
pneumatic alternating stockings |
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Term
complications of immobility on respiratory system 1
due to venous issues |
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Definition
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Term
| signs of pulmonary embolism |
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Definition
| dyspnea,wheezing, hemoptysis (coughing blood), tachycardia, apprehension, chest pain, low fever |
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Term
respiratory complications 2
lungs |
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Definition
secretion formation
atelectasis (collapsed alveoli)-bronchus is blocked with secretions affecting alveoli oxygen absorption
hypostatic pneumonia- pooling of scretions can lead to infection |
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Term
| preventing secretion formation and subsequent issues |
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Definition
| cough deep breath, use incentive spirometer q2h, increas the head of bed angle, reposition, increase fluids to thin secretions, suctioning |
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Term
| rational for TEDS and other compression devices |
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Definition
| TEDS and other devices mimick the body's nautral mechanism for venous return, allowing the heart to work at normal capacity and decreasing the probability of orthostatic hypotension. |
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Term
| preventing GI complications due to immobility |
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Definition
Fiber
vitamins
fluids
stool softeners
ememas
reassess pain medication |
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Term
| role of calcium in immobility issues |
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Definition
| calcium is leached from the bones due to disuse, cauaing pourous and brittle bones; increased calcium in the blood causes kidneys to become overwhelmed causing kidney stones |
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Term
| promoting psycho-social needs of an immobile patient |
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Definition
| encourage social stimulation and interaction, encourage motivation to maintain positive self image, provide intellectual stimulation, educate |
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Term
| special dietary needs due to immobility |
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Definition
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Term
| immobility nursing diagnosis labels |
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Definition
mobility, physical impaired
disuse syndrome, risk for
skin integrity, impaired, (or risk for)
tissue perfusion ineffective peripheral
activity intolerance
airway clearance, ineffective
gas exchange, impaired
fluid volume deficit, risk for
infection risk for
urinary elimination, impaired
body image, disturbed
coping, ineffective |
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Term
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Definition
| indicated when patient is able to help move and does not tire easily. also indicated pre-op. |
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Term
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Definition
| only cleaning the areas that cause odor |
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Term
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Definition
| 45-60 degrees, knees slightly elevated |
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Term
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Definition
almost 90 degress
good for eating, oral hygiene, and COPD patients |
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Term
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Definition
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Term
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Definition
| on back. leads to greatest number of pressure ulcers: occipital, vertebrae, coccyx, heels |
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Term
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Definition
| supine with legs flexed, relaxes abs |
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Term
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Definition
| chest down, least risk of pressure ulcers, but least realistic for care |
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Term
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Definition
side lying
30 degree lateral reccommended for those at risk for pressure ulcers |
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Term
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Definition
| between prone and lateral |
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Term
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Definition
| bed frame tilter so head down feet up |
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Term
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Definition
| bed frame tilted feet down |
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Term
| role of the nurse in medication administration |
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Definition
| to prepare the patient and family for independent medication administration at home |
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Term
| parts required on a written medication order |
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Definition
| patient name, correct med name, correct med dose and route, time and frequency of administration, signature |
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Term
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Definition
| policies vary but generally it s proper to write the order down and have the physician co-sign at a later time (like 2o minutes!) |
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Term
| policies of heparin and insulin |
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Definition
| both must be checked by two nurses for correct dose and expirations |
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Term
| medication right number 1 |
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Definition
RIGHT PATIENT
always request patient identify their name and birthdate verbally, never yes/no |
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Term
| medication right number 2 |
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Definition
RIGHT DRUG
check 3 times
when removed from storage
when preparing
right before administering
beware of similar labels/names or trade names vs. generics |
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Term
| medication right number 3 |
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Definition
RIGHT DOSE
measure by final concentration, double check, refer to original written order if it seems unusual in any way |
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Term
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Definition
RIGHT TIME
military time
stat orders
single orders
prn;pain, sleep record EXACT time in MAr |
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Term
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Definition
RIGHT ROUTE
easy to make errors here
be sure the written order is completely legible.
route can only be changed by the MD |
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Term
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Definition
RIGHT RATIONAL
is this drug being given for the correct issue?
do you know why it is being given?
can you see the positive effects? |
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Term
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Definition
RIGHT DOCUMENTATION
type of medication stat/scheduled/prn affects the time given charting
was the med held? thrown up? refused? |
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Term
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Definition
RIGHT RESPONSE
was it effective? |
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Term
| primary unit metric weight |
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Definition
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Term
| primary unti metric volume |
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Definition
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Term
| primary unit apotecary weight |
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Definition
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Term
| primary unit apotecary volume |
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Definition
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Term
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Definition
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Term
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Definition
drop
1 drop=1 minim
15 drops = 1 ml |
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Term
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Definition
check abel 3 times.
be aware MAR label might be different
avoid confirmation bias "looks familier"
know your rational
GIVE ONLY WHAT YOU PREPARE!
listen to your patient if they think its wrong. |
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Term
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Definition
1. asess patient (TPR/BP)
2. call charge and MD
3.fill out the error, variance, form
4. monitor partient
5. modify your checks for this to not happen again |
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Term
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Definition
documentation of sitation, not necessarily problem oriented
can organize progres notes |
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Term
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Definition
| only documentation of the abnormal |
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Term
| 6 factors promoting accuracy |
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Definition
militray time
black ink
correct abbreviations, spelling, legible
no blank spaces
corrections made per policy
chart only for yourself |
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Term
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Definition
admmissions form
graphic (vital signs) sheets
Medication Records MAR
I&O
Flowsheets
KArdex
24 acuity care flow sheet
Standardized care plans
discharge summary forms |
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Term
| Legal aspects of Documentation |
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Definition
Objective and Factual
Acurate
Organzied (begin w/time end w/signature)
black ink
correct abbreviations and spelling
Legible
no blank space
correct errors only in hospital policy way
nevr chart for someone else
NO XEROXING
adhere to patients bill of rights
no ciriticism of other professionals
elimiate bias from descriptions
document any non-compliance |
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Term
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Definition
THe way to talk to the MD
Situation
Background
Assessment
Reccomendation |
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Term
| recording drugs on the MAR |
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Definition
1. record on MAR as it is given, not before
2. document refusals/misses
3. sign
for special citcumstances, countersignature
insulin-blood glucose
cardiac drugs- apical rate
antihypertensives-BP value
injections- site recorded
heparin- counter signature |
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Term
| medication routes that are CLEAN |
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Definition
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Term
| medication routes STERILE |
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Definition
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Term
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Definition
via GI tract
systemic effect
slow onset
cheap
safe
easy |
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Term
| sublingual med absorbtion |
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Definition
disolves under tounge
asorbed quickly, not altered by digestion issues |
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Term
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Definition
| acts locally on mucous membranes of the cheek and sysemically when swallowed with saliva |
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Term
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Definition
local effect
creams, ointments, patches/pads
also
instillations and irrigations: applied to body cavities
eye drops :STERILE
ear/nose clean technique |
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Term
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Definition
| identify patients at risk for or experiencing electrolyte imbalance |
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Term
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Definition
1. replacement therapy (surgey, trauma, intolerance in GI tract)
2. maintenance line (NPO, comatose, GI upset)
3.Nutrition- TPN central line
4. IV meds |
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Term
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Definition
shifts fluids from vein into cell.
D5w
1/2 (.45)NS
d50.2NS |
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Term
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Definition
keeping the balance or for lost blood
NS (0.9)
LR
D5NS
D10W
D5LR |
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Term
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Definition
dehydrates cells and infuses veins,
good for low blood sugar
D10NS
d20W
TPN
3%NS |
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Term
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Definition
| R subclavian, jugular, PICC, femoral |
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Term
| rational behind a triple lumen |
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Definition
| each lumen is separate for administration of medications with contraindications. 3 separtate lines wrapped together into one sheath for ease of insertion |
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Term
| central line advantages ( 2 required) |
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Definition
1. long term solutions for chemo or TPN
2. irritating medications
3.larges volumes
4. CVP monitoring |
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Term
| central line insertion complications |
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Definition
1. pneumothorax
2. air embolism
3.sepsis
4.dysrhythmia |
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Term
| central line care complications |
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Definition
1.bleeding out the line
2.thrombus
3.occlusion
infiltration, extravasation (toxic) |
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Term
| CDC guidlines for IV tubing change |
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Definition
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Term
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Definition
| veins, artery, peritoneal space, nerve plexus |
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Term
| solution for flushing open tip central catheter |
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Definition
| open tip flush with heparin |
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Term
| solution for flushing valve tip |
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Definition
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Term
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Definition
chemical from medications
becterial from unclean techniques
mechanical from moving around to much |
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Term
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Definition
| pain, edema, erythema, warmth |
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Term
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Definition
| cool, pallor, edema, pain |
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Term
| how long do IV solutions last after seal is broken? |
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Definition
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Term
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Definition
| inadvertant administration of a non vesicant solution into surrounding tissues |
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Term
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Definition
| accidentally admiinistering vesicant meds into the surrounding tissue |
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Term
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Definition
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Term
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Definition
1. fluid volume excess - increased retention and edem r/t rapid iv infusion
2.luid volume deficit- vascualar and cellular dehydration r/t GI loss and decreased PO intake
3. at risk for fluid volume deficit- r/t nausea, aging
4.tissue integrity impaired- r/t infiltration, phlebitis, dehydration, edema
5.oral mucous membrane altered - r/t loss of fluid. |
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Term
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Definition
| keep vein open, 20-30 mls/hr |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
| criteria selecting volumetric pump |
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Definition
lesss than 50mls hr, greater than 150mls hr
all DRIPS
all central lines, midlines, arterial lines, port-a-cath |
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Term
| criteria for gravity pump |
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Definition
tko, volume not critical
rates between 50-150 mls/hr
solutions with additives not concentrated |
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