Term
| first step of nursing process |
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Definition
Problem:
describes the health state conciesely
Based on standard nomenclature
Suggests patient outcomes |
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Term
| Second step of nursing process |
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Definition
Etiology
Frequently based on patient:
Lack of knowledge about
Lack of ability to
Lack of motivation for |
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Term
| Third step of nursing process |
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Definition
Defining Characteristics
data suggests the existance of the problem
Suggests evaluation criteria |
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Term
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Definition
Problem Related to (R/T)___ as evidenced by (AEB) ____.
Problem = what is wrong
Etilogy - R/T = lack of knowledge, ability, motivation
Defining Characteristics - AEB = those assessment items that lead you to the diagnosis |
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Term
| Relate nursing diagnosis to outcomes; inteventions and evaluations |
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Definition
1. design a plan of care for the patient that is consistent with patient goals and values
2. REsolves the problems idd in the RN diagnosis
3. outcomes are based on sound priorities and sound evidence
4. Meets professional standards
5. Outcomes should be based on problem statement
6. Interventions should be based on etiology |
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Term
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Definition
| From the National Council for Excellence in Critical Thinking (NCECT) "...the intellectually disciplined process of actively and skilfully conceptualizing, applying, analyzing, syntehsizing, and/or evaluating information gatehred from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action." |
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Term
| Applying critical thinking to problem solving |
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Definition
1. Nursing process is systematic dynamic problem solving model used in nursing
2. Nursing process is composed of ADPIE
3. Nursing process is one model of critical thinking
4. Critical thinking is a learned skill t hat must be developed
5.Critical thinking in nursing is based on both self-knowledge an dnursing science
6.Barriers to effective decision making are based in personal issues and lack of knoweldge |
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Term
| 5 Steps of the nursing process |
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Definition
ADPIE
Assess
Diagnose
Plan (set goals)
Implement
Evaluate |
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Term
| Benefits of Nursing Process |
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Definition
* Provides Care that is Holistic, Science Based & Individualized
* Allows for continuity of care
*Allows for collaboration with nurses
*Clear cost effective plan of care
*Assures teamwork
* Gives way to grow by evaluating outcomes |
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Term
| Two types of data involveed in nursing assessment |
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Definition
Objective - measureable and observable
Subjective - depends on the perspective of the patient |
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Term
| Significance of Tanner's Model |
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Definition
| Tanners model takes into account the context of the situation and that actions require constant evaluation |
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Term
| Blocks to effective decision making |
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Definition
*Failure to consider total situation
- Using inacurrate data
- Not clearly IDing problem
- Failure to prioritize or rank the problems
- Unrealistic goals
* Knowledge based problem
* Requires learning & experience
* Impatience
- failure to id multiple solutions
- incorrect implementation
- Failing to use resources or using wrong resources
*Intrapersonal & knowledge problems |
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Term
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Definition
* all old people are on multiple medications
* seniors don't have sex
* seniors are not physically active
* seniors are rigid/narrow minded
* seniors are poor, lonely, and in frail health |
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Term
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Definition
| A form of prejudice in which older adults are sterotyped by characteristics found in only a few of their age group |
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Term
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Definition
| A type of dementia; is the most common degenerative neurologic illness and most common cause of cognitive impairment |
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Term
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Definition
| downward spiral or sequence of adverse events often triggered by a medical or surgical intervention during the hospitalization of an older adult |
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Term
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Definition
| a temporary state of confusion |
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Term
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Definition
| organic impairment of intellectual functioning, gradually leading to interference with social or occupational functioning, memory, and often personaility integration |
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Term
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Definition
| Level of health defined by one's ability to carry out usual and desired daily activities |
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Term
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Definition
| Nursing specialty concerned with the care of the older adult |
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Term
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Definition
| Study of all aspects of the aging process |
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Term
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Definition
| Universal phenomenon identifed by Butler as a review of one's life through one's recollections |
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Term
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Definition
| refers to adults between the ages of 40 - 60 years |
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Term
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Definition
| adults over the age of 65 |
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Term
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Definition
| the use of multiple medications at the same time |
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Term
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Definition
| Metod of care used to promote awareness of reality in confused or disoriented patients |
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Term
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Definition
| To think back over things you have done in the past |
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Term
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Definition
| Sense of aloneness because of decreasing relationships with others, resulting from attitudinal, geograaphic, financial, or illness-related factors |
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Term
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Definition
| Describes a phenomenon when a person habitually becomes confused or disoriented with darkness |
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Term
| Atypical presentation of illness |
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Definition
| signs and symptoms that are not usually associated with a particular illness |
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Term
| Normal physiological chanages of aging |
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Definition
all organ systems undergo some degree of decline in overall functioning and the body becomes less efficient.
-thin skin
-decreased BMD
-Decreased muscle tone
-Change in vision & hearing
-Slower elimination
-Increased chance of incontinence |
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Term
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Definition
| Episode of pain that lasts from seconds to less than 6 months |
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Term
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Definition
| Episode of pain that lasts for 6 months or longer; may be intermittent or continuous |
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Term
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Definition
| Period in a chronic illness when the disease is present, but the person does not experience symptoms of the disease |
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Term
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Definition
| Period in chronic illness when the symptoms of the disease reappear |
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Term
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Definition
| Pain related to cancer or disease process |
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Term
| Chronic nonmalignant pain |
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Definition
| non-cancerous and lasting longer than 6 months |
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Term
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Definition
| Superficial paian usually involving the skin or subcutaneous tissue |
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Term
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Definition
| Pain that is sticking in nature and that is intense |
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Term
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Definition
| Pain that is not as intense or acute as sharp pain |
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Term
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Definition
| Pain that covers a large area |
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Term
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Definition
| Pain originating deep in the structures of the body |
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Term
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Definition
| Pain originating in the internal organs in the thorax, cranium, or abdomen |
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Term
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Definition
| Severe pain that is extremely resistant to relief measures |
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Term
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Definition
| Sensation of pain without demonstrable physiologic or pathologic substance; commonly observed after the amputation of a limb |
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Term
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Definition
| Pain for which no physical cause can be identified |
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Term
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Definition
| Pain that results from an injury to or abnormal functioning of peripheral nerves ior the central nervous system |
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Term
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Definition
| Pain in an area removed from that in which stimulation has its origin |
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Term
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Definition
| Pain that moves from one area to another |
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Term
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Definition
| Degree of pain (i.e., severe or excruciating, moderate, slight or mild) |
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Term
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Definition
| Rate of recurrence (i.e., Continuous, Intermittent, Brief or transient) |
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Term
| Common barriers to pain assessment |
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Definition
| Culture, ethnic, family, gender, age, anxiety/stress, past pain experience |
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Term
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Definition
behavioral
physiological (mild/moderate/severe)
Psychological |
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Term
| Ethnocultural responses to pain |
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Definition
Stoicism/Machismo
Fear
Doubtful |
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Term
| Pain considerations for older adults |
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Definition
* communication difficulties
* denial of pain
* altered physiologic responses |
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Term
| Utilize nursing process for a patient with acute dental pain |
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Definition
Assessment - use COLDSPA
Nursing Diagnosis - use NANDA |
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Term
| QSEN competencies around comfort |
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Definition
| by using evidence based practice, it allows us to assess and utilize comfor measures that are proven to be effective. Teamwork and Collaboration allows for open communication between the patient, nurse, and other healthcare professionals. Patient-centered care allows the patient to direct care according to their needs. Timely updating of informatics is imporatnt to quality care. |
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Term
| Identify various aspects of culture |
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Definition
A shared way of life passed from generation to generation by learning, not heredity
-what people think, do and what they produce
-Much is implied, but not spelled out
-includes: norms, vlaues, beliefs, knowledge, learned behaviors, social organization |
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Term
| Describe aspects of culture that impact perceptions of health and health care |
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Definition
-Language barriers
-cultural norms: middle eastern male not wanting treatment from a female physician
Germans tend to be morestoic and therefore don't show pain as easilty
-Latinos getting a majority of their medical advice from family members
-Some examples but really, any aspects of culture (norms, values, belifs, knowledge, learned behaviors and social organizatio) listed above can impact perceptions of health and health care |
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Term
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Definition
| Culturally Linguistically Appropriate Standards |
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Term
| First role of CLAS standards |
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Definition
| Health care organizations should ensure that patients receive, from all staff members, effective, understandable and respectful care that is provided in a manner compatible with their cultural health beliefs. This means don't give a Jehovah's witnesses blood transfusions, respect the fact that they think that they are possessed by a demon when they actually have a seizure disorder and sere an Indian person at the hospital a vegetarian diet (examples) |
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Term
| Second role of CLAS standards |
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Definition
| Health care organizations should implement strategies to recruit, retain and promote, at all levels of the organization, a diverse staff and leadership that are representative of the demographic characteristics of the service areea. This means that if you live in Texas, you should probably have a representative population of Latino workers in your hospital, at all different levels of the hospital. |
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Term
| Third role of CLAS standards |
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Definition
| Health care organizations should ensure that staff, at all levels and across all disciplines recieve ongoin education and training in culturally and linguistically appropriate service of delivery. Culture change and different types of cultures move into an area and you want your hospital staff ahead of the curve as far as these changes go. |
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Term
| Perform a culturea assessment using the Kleinman questions |
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Definition
-What do you think caused the problem?
- Why do you think it happened when it did?
- What do you think your sickenss does to you? How does it work?
- How severe is your sickness? Will it last long?
- What kind of treatment do you think you should recieve?
-What are the most important results you hope to receive from this treatment?
-What are the chief problems your sickness has cause for you?
- What do you fear most about your sickness? |
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Term
| Potential RN diagnosis related to cultural differences |
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Definition
- Social Isolation R/T recent move away from neighborhood and friends of same ethnic group
- Impaired parenting R/T use of culturally based discipline considered inappropriate or abusive by current country or residence.
-Spiritual distress related to inability to take part in significant culturally based rituals regularly
- Readiness for enhanced family process related to request for information about child care
-Ineffective managment of therapeutic regiment R/T misturst of traditional healthcare personnel
-Situational low-self esteem related to language difficulties and inability to secure employment
-Powerlessness R/T inability to make healtcare providers understand the importance of dietary and social values and beliefs. |
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Term
| Maslow's First Level of needs, applied to patient care situations |
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Definition
Physiologic needs:
the most basic needs: Oxygen, water, food, temperature, elimination, sexuality, physical activity and sleep. All must be met to maintain life and therefore have the highest priortiy for nursing care |
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Term
| Maslow's Second Level of needs, applied to patient care situations |
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Definition
Safety and Security -
- using proper hand hygiene and sterile techniques to prevent infection
-using electrical equipment properly
- Administering medications knowledgably
-Using skill when moving and ambulating patients
-Teaching parents about houshold chemicals that are dangerous to children |
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Term
| Maslow's Third Level of needs, applied to patient care situations |
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Definition
Love and belonging needs
- these needs include the understanding and acceptance of others in both giving and receiving love, and the feeling of belonging to families, peers, friends, a neighborood and a community.
-including family and firends in the care of the patient
-Establishing anurse-patient relationship based on mutual understanding and trust by demonstrating caring, encouraging communication and respecting privacy.
-Referring patients to specific support groups, such as alcoholics nonymous and cancer support groups |
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Term
| Maslow's Fourth Level of needs, applied to patient care situations |
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Definition
Self-esteem needs
-nurses can help meet patients' self-esteem needs by respecting their vlaures and beliefs, help patient set attainable goals, facilitatin support from family members. Nurses must remember that after a mastectomy or injury, that it is the person's perception of change rahter than the actual change itself, is what affects the individuals self-esteem |
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Term
| Maslow's Fifth Level of needs, applied to patient care situations |
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Definition
Self-actualization (highest level)
-Acceptance of self and others as they are
-Focus of interest on problems outside of oneself
-Ability to be objective
-Feelings of happiness and affection for others
-Respect for all people
-Ability to discriminate between good and evil
-Creativity as a guidline for solving problems and pursuing interests
-Nurses focus on the person's strengths and possibilities rather than the problems. Nursing interventions are aimed at providing a sense of direction and hope and providing teaching that is aimed at maximizing potentials. |
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Term
| impact of health on family roles, structure and tasks |
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Definition
-physical: problems providing safe and comfortable environment for growth and development for you and your family
-Economic: problems financially providing for family
Reproductive: problems raising or having children
-Affective and coping: problems providing emotional comfort or have clear identity and stability during times of stress
-Socialization: problems transmitting beliefs, values, attitudes and coping mechanisms and solving problems within the family.
-The family structure is affected by others having to "take up the slack" of the roles of the person who is sick or injured. |
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Term
| Health promotion and care giving in relationship to the family |
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Definition
1. family is composed of interdependent members who affect one another. If some form of illness occurs in one memeber, all other members become a part of the illness.
2. A strong relationship exists between the family and the health status of it's members, therefore, the role fo the family is essential in every level of nursing care.
3. The level of health of the family, and in turn, each memeber can be significantly improved through health promotion activities.
4. Illness of one family member may suggest the possibility of the same problem in other memebers. Through assessment and intervention, the nurse can assist in improving the heatlh status of all family members |
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Term
| Developmental tasks of older adults impact on nursing interactions |
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Definition
| The nurse should help the client reminisce and life review. The nurse may need to provide and/or educate about adaptave aids, budgeting and meal planning, grief counseling, encourage socialization, anticipatory guidance, environmental assessment, and problem solving. |
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Term
| How health, illness, stages of development affect sexual identiy and sexual expression |
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Definition
Sexual expression - visual stimulation, fetishes, and role play. Self knowledge is an important factor, awareness of alternate forms of sexual expression.
-young adults need knowledge for risky behaviors an d prevention of pregnancy and STI's
-Older adults: plan for sexual activity, alternate positioning for pain and mobility, instability, lubricants for vaginal dryness, overcoming erectible dysfunctions (sex in am, medicines, & masterbating) |
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Term
| How do perosnal values & beliefs impact ability to provide nursing care to patients with sexual problems |
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Definition
-know personal boundaries, and comfort level with sexuality; develop self awareness, develop communication skills
-increase knowledge of normal sexual response and information on how to support patient's sexual functioning |
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Term
| Nursing diagnosis ID'ing sexuality problems |
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Definition
| Sexual dysfunction R/T use of antihypertensive medication AEB pt appears resigned and saddened |
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Term
| Personal/professional boundaries in regards to sexual harassment |
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Definition
Definition - unwanted behavior that is sexually or gender based; can create hostile work enviornment, can come from patient, colleague, or superior
Patient: set and enforce limits, report, confront |
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Term
| Havighurst - infancy to toddler hood |
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Definition
| physiological stability, learning to eat, walk, talk; forming concepts of reality; relate emotionally, control elimintation of wastes, distinguis btwn right and wrong; sex difference and modesty |
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Term
| Havighurst - preschool to early school years |
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Definition
| physical skills for games; socal interaction; fundamental skills of reading, writing, math; development of conscience, morality and vlaues, personal independence |
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Term
| Havighurst - School years |
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Definition
| Acceptance of ones body and correct usage, gender role, emotional independence, preparing for family, marriage, and career, displaying sexual responsibility, achieving ethics |
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Term
| Havighurst - adolescent to young adult |
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Definition
| selecting a mate, living with marriage partner, rearing children, managing a home, gettin started in an occupation, taking civic responsibility, finding a congenial social group |
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Term
| Havighurst - middle adult |
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Definition
| accepting and adjusting to physical changes, attaining and maintaining a job, assisting children to become responsible adults, relating to your spouse, adjusting to aging parents, social and civic responsibilty |
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Term
| Havighurst - ego vs. despair |
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Definition
| Adjusting to decreasing physical strength, retirement, reduced income, declining health, and death of spouse; established an explicit affilation with age group; social role acceptance, establishing living arrangements. |
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