NUR 501 Exam II

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NUR 501 Exam II
2014-03-02 15:15:40
Shea 502 ExamII
Nur 501 Exam II
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  1. GI Tract Functions 
    Digestion begins with mastication.
  2. GI Tract Functions
    Peristalsis moves food into the stomach.
  3. GI Tract Functions Stomach
    Stores food; mixes food,liquid, and digestive juices;moves food into small intestines
  4. GI Tract Functions Small intestine
    Duodenum, jejunum, and ileum
  5. GI Tract Functions Large intestine
    • The primary organ of bowel elimination.
    • Some absorpt. of H20 and electrolytes
  6. GI Tract Functions Anus
    Expels feces and flatus from the rectum
  7. Factors Critical to Bowel Function and Elimination (5)
    • Normal GI tract function
    • Sensory awareness of rectal distention and rectal contents
    • Voluntary sphincter control
    • Adequate rectal capacity
    • Compliance
  8. Factors Affecting Bowel Elimination (11)
    • Age Diet
    • Fluid intake
    • Physical activity
    • Psychological factors
    • Personal habits
    • Position during defecation
    • Pain
    • Pregnancy
    • Surgery and anesthesia
    • Medications, laxatives,and cathartics
    • Diagnostic tests
  9. Action of dicyclomine HCI on GI system
    suppresses peristalsis and decreases gastric emptying
  10. Action of opioid analgesics on GI system
    slow peristalsis and segmental contractions often results in constipation
  11. Action of anticholinergic drugs such as atropine or glycopyrolate (Robinul) on GI system
    inhibit gastric acid secretion and depress gastrointestinal motility

    (Although helpful in treating hyperactive bowel disorders- cam cause constipation)
  12. Action of antibiotics on GI system
    produce diarrhea by disrupting the normal bacterial flora in the GI tract
  13. Action of non-steroidal anti-inflammatory drugs on GI system
    cause GI irritation that increases the incidence of bleeding with serious consequences to older adults; rectal bleed is often observed w/ GI irritation
  14. Action of aspirin on GI System
    prostaglandin inhibitor; interferes w/ the formation and production of protective mucus and causes GI bleeding
  15. Action of Histamine on GI system
    suppress the secretion of hydrochloric acid and interfere with the digestion of some foods
  16. Action of iron on GI system
    causes discoloration in the stool (black), nausea, vomiting, constipation (dia. is less commonly reported), and abdom. cramps
  17. GI Tract Normal Age-Related Changes Mouth
    Decreased salivation and mastication
  18. GI Tract Normal Age-Related Changes Esophagus
    Decreased motility
  19. GI Tract Normal Age-Related Changes Small intestine
    Decreased nutrient absorption - make sure they are getting nutrient rich foods
  20. GI Tract Normal Age-Related Changes Large intestine (3)
    • Increase in intestinal wall pouches
    • Constipation
    • Missed defecation signal
  21. GI Tract Normal Age-Related Changes Liver
    Decreased size
  22. GI Tract Normal Age-Related Changes Stomach
    Decreased acid secretions, motor activity & mucosal thickness
  23. Amt of Fluid for reg. BM
    1100-1400 mL daily
  24. Common Bowel Elimination Problems (6)
    • Constipation 
    • Impaction
    • Diarrhea
    • Incontinence
    • Flatulence
    • Hemorrhoids
  25. Constipation
    A symptom, not a disease;infrequent stool and/or hard, dry,small stools that are difficult to eliminate
  26. Impaction (GI)
    Results from unrelieved constipation; a collection of hardened feces wedged in the rectum that a person cannot expel
  27. Diarrhea
    an increase in the number of stools and the passage of liquid, unformed feces
  28. Incontinence (GI)
    Inability to control passage offeces and gas to the anus
  29. Flatulence
    Accumulation of gas in the intestines causing the walls to stretch
  30. Hemorrhoids
    Dilated, engorged veins in the lining of the rectum
  31. Stoma
    Temporary or permanent artificial opening in the abdominal wall
  32. Ileostomy or colostomy
    Surgical opening in the ileum or colon
  33. The standard bowel diversion creates a ____
  34. Ostomies (Types-3)
    • Loop colostomy
    • End colostomy
    • Double-barrel colostomy
  35. Loop colostomy
    This is temporary in the transverse colon.
  36. End colostomy
    Proximal end forms stoma, and distal end is removed or sewn closed.
  37. Double-barrel colostomy
    Bowel is surgically cut, and both ends are brought through the abdomen.
  38. Assessment (GI) (15)
    • Usual elimination pattern
    • Patient description of stool characteristics
    • Routines to promote normal elimination
    • Use of artificial aids at home
    • Presence & status of bowel diversions
    • Changes in appetite 
    • Diet history
    • Daily fluid intake
    • Surgery/illness affecting GI tract
    • Medication history
    • Emotional state
    • History of exercise
    • History pain/discomfort
    • Social history
    • Mobility & dexterity
  39. Assessment (GI) Physical assessment (3)
    • Mouth,
    • abdomen, and
    • rectum
  40. Assessment (GI) Laboratory tests (2)
    • Fecal characteristics
    • Fecal specimens
  41. Assessment (GI) Diagnostic examinations
    • Radiologic imaging, with or without contrast
    • Endoscopy
    • Ultrasound
    • Computed tomography (CT) or
    • magnetic resonance imaging(MRI)
  42. Promoting Healthy Bowel Habits
    • Proper Fluid and Food Intake
    • Regular exercise
    • Maintenance of Skin Integrity
  43. Promoting Healthy Bowel Habits
    Proper Fluid and Food Intake
    • Goal – normal elimination
    • Assess defecation frequency, feces character andproblem foods
  44. Promoting Healthy Bowel Habits
    Regular exercise
    Ambulate as soon as possible in acute care
  45. Promoting Healthy Bowel Habits Maintenance of Skin Integrity
    High risk for skin breakdown with fecal incontinence or diarrhea
  46. Anuria
    No urine produced
  47. Bacteriuria
    Bacteria in the urine that leads to the spread of organisms into the kidneys and possible leads to bactereima or urosepsis (bacteria in the bloodstream)
  48. bactereima or urosepsis
    bacteria in the bloodstream
  49. Cystitis
    Inflammation of the bladder.
  50. Proteinuria
    Presence of large proteins in the urine. (Kidneys do not filter large proteins. Normally insulin will break down but if insufficient will lead to proteinuria)
  51. Erythropoietin
    A hormone produced and released by the kidney that stimulates the production of red blood cells by the bone marrow.(Kidney diseases=decreased production=anemia)
  52. Micturition
    Urination; the act of voiding
  53. Uremic Syndrome
    increase in nitrogeneous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions
  54. Nocturia
    Awakening to void one or more times at night.
  55. Oliguria
    Decreased urine output.
  56. Polyuria
    Excessive urine output
  57. ESRD- End Stage Renal Disease
    Irreversible damage to the kidney tissue
  58. ARF- Acute Renal Failure
    Reversible; Sudden loss of function; Overdose, meds, posioning, excessive blood loss can progress to chronic renal failure
  59. Urinary Retention.
    An accumulation of urine due to the inability of the bladder to empty. Void small amounts 2-3 times per hour. Bladder distension/fullness
  60. Urinary Incontinence
    Involuntary leakage of urine
  61. Dysuria
    Pain or burning during urination. (Associated with lower UTIs as urine flows over inflamed tissues)
  62. Hematuria
    Blood-tinged urine
  63. Pyelonephritis
    Kidney infection
  64. Stress Incontinence Interventions 5
    • Kegels
    • Surgical intervent.
    • biofeedback
    • electrical stimulations
    • absorbent products
  65. Stress Incontinence S/S
    Loss of urine w/ increased intraabdominal pressure (coughing, laughing, sneezing, or lifting w/ full bladder.)
  66. Stress Incontinence
    Involuntary leakage of urin during increased abdominal pressure in the absence of bladder muscles contraction
  67. Functional Incontinence
    Cant get to the bathroom on time (temporary); External reasons; Intact nervous system; Schedule toileting
  68. Urge Incontinence
    Involuntary; passage of urine after a strong sense of urgency to void
  69. Ureostomy
    Ureters brought to the abdominal surface. Two collection bags. Transureterostomy where the two ureters are connected into one
  70. Nephrostomy
    Tube placed directly into the renal pelvis
  71. Specific Gravity
    The weight or degree of concentration of a substance compared with an equal volume of water. Normal Range 1.010-1.030
  72. Additional Kidney Functions
    • Production of erythropoietin is essential to maintaining a normal red blood cell (RBC) volume.
    • Production of renin, prostaglandin E2, and prostacyclin affects blood pressure.
    • Kidneys affect calcium and phosphate regulation
  73. Kidneys function
    • Remove waste from the blood to form urine
    • fluid and electrolyte balance
  74. Act of Urination Brain structures:
    influence bladder function.
  75. Act of Urination 
    Bladder contraction + Urethral sphincterand pelvic floor muscle relaxation
  76. Act of Urination Steps (3)
    • 1. Stretching of bladder wall signals the micturition center in the sacral spinal cord.
    • 2. Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.
    • 3. When a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties.
  77. Factors Influencing Urination (11)
    • Disease conditions
    • Medications and medical procedures
    • Surgical procedures
    • Diagnostic examination of urinary system
    • Sociocultural factors (need for privacy)
    • Psychological factors (anxiety, stress, privacy)
    • Fluid balance ( Nocturia, polyuria, oliguria, anuria)
    • Diuresis
    • Fever
    • Growth & Development

    Muscle tone
  78. Medical Interventions Affecting Urination Surgical procedures
    Restriction of fluid intake lowers urine output. Stress causes fluid retention.
  79. Medical Interventions Affecting Urination Diagnostic examinations
    • Restriction of fluid intake lowers urine output
    • Direct visualization causes localized trauma and edema;patients may have difficulty voiding.
  80. Medical Interventions Affecting Urination 
    • Some cause urinary retention and/or overflow incontinence.
    • Some cause urgency and incontinence.
    • Some change the color of urine.
  81. Disease Conditions Affecting Urination 8
    • Prerenal, renal, postrenal classification
    • Conditions of the lower urinary tract
    • Diabetes mellitus and neuromuscular diseases such asmultiple sclerosis
    • Benign prostatic hyperplasia
    • Cognitive impairments (e.g., Alzheimer’s)
    • Diseases that slow or hinder physical activity
    • Conditions that make it difficult to reach and use toiletfacilities
    • End-stage renal disease, uremic syndrom
  82. Alterations in Urinary Elimination 4
    • Urinary retention
    • Urinary tract infection
    • Urinary incontinence
    • Urinary diversion
  83. Assessment- Urinary
    Nursing History
    • patient’s urination pattern and symptom
    • factors affecting urination
    • identify urinary alterations
  84. Assessment- Urinary
    • Nursing History
    • Physical assessment
    • Assess urine
    • Assess the patient’s perception of urinary problems as it affects self-concept and sexuality.
    • Gather relevant laboratory and diagnostic test data.
  85. Assessment- Urinary
    Physical assessment (patient’s body systems potentially affected by urinary change).
    • Skin and mucosal membranes
    • Kidneys & bladder
    • Urinary meatus
  86. Assessment- Urinary
    Assess urine
    • Intake and output
    • Urine characteristics (color, clarity, odor)
  87. Normal Urine pH
  88. Normal Urine Protein
    none- 8mg/100mL
  89. Normal Urine Glucose
  90. Normal Urine Ketones
  91. Normal Urine Blood
  92. Normal Urine Specific Gravity
  93. Interventions for Urinary System
    Acute Care
    • Maintaining elimination habits
    • Medications
    • Catheterization
  94. Indications for Catheterization
    Intermittent Cath.
    • Relieving discomfort of bladder distention, providing decompression
    • obtaining sterile urine specimen, when clean catch is unavail.
    • Assessing residual urine after urination
    • managing pts w/ spinal cord inj., neuromusclar degeneration, or incompetent bladder long term
  95. Indications for Catheterization
    Short-term indwelling cath.
    • obstruction to urine outflow
    • surgical repair of bladder, urethra and surrounding struct.
    • prevention of urethral obstruction from blood clots after genitourinary surgery
    • measurement of urinary output in crit. ill pts
    • continuous or intermittent bladder irrigations
  96. Indications for Catheterization
    Long- Term indwelling cath
    • severe urinary retention w/ recurrent episodes of uti
    • skin rash, ulcers, or wounds irritated by with urine
    • terminal illness when bed linen changes are painful for pts
  97. Interventions for Urinary System Restorative Care
    • Pelvic floor strengthening
    • Bladder retraining
    • Habit training
    • Self – catheterization
    • Maintaining skin integrity
    • Promotion of comfort
  98. Special Consideration for Older Adults- Urinary
    • Provide frequent opportunities to void. Older adults have a smaller bladder capacity than younger adults.
    • Encourage older adults to empty the bladder completely before and after meals and at bedtime.
    • Encourage patients to increase fluid intake to at least six to eight glasses a day unless medically contraindicated.
  99. Confidentiality- Nurses are ____ & ____obligated to keep all patient information confidential.
    legally and ethically
  100. Nurses are responsible for protecting records from:
    all unauthorized readers.
  101. ______ requires that disclosure or requests regarding health information are limited to:
    HIPAA; the minimum necessary.
  102. Standards: Current documentation standards require that eachpatient have an assessment
    Physical, psychosocial, environmental, self-care, patient education, knowledge level, and discharge planning needs
  103. Purposes of Records 6
    • Communication
    • Legal documentation
    • Reimbursement
    • Education
    • Research
    • Auditing/monitoring
  104. Legal Guidelines for Recording 9
    • Correct all errors promptly, using the correct method.
    •  Record all facts; do not enter personal opinions.
    • Do not leave blank spaces in nurses’ notes.
    • Write legibly in permanent blank ink.
    • If an order was questioned, record that clarification was sought.
    • Chart only for yourself, not for others.
    •  Avoid generalizations.
    • Begin each entry with the date/time and end with your signature and title.
    •  Keep your computer password secure.
  105. Guidelines for Quality Documentation and Reporting
    • Factual
    • Accurate
    • Complete
    • Current
    • Organized
  106. Methods of Recording: Progress Notes
    • Subjective,
    • objective,
    • assessment,
    • plan
  107. Methods of Recording: Progress Notes 
    • Subjective,
    • objective,
    • assessment,
    • plan,
    • intervention,
    • evaluation
  108. Methods of Recording:
    • Problem,
    • intervention,
    • evaluation
  109. Methods of Recording:Focus charting (DAR)
    • Data,
    • action,
    • response
  110. Methods of Reporting
    • Source records: A separate section for each discipline
    • Charting by exception (CBE):Focuses on documenting deviations
    • Case management plan and critical pathways:Incorporate a multidisciplinary approach to care- Variances
  111. Home Care Documentation
    • Medicare has specific guidelines for establishing eligibility for home care.
    • Medicare guidelines for establishing a patient’s home care cost reimbursement serve as the basis for documentation by home care nurses.
    • Documentation is the quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.
    • Nurses need to document all their services for payment.
  112. Hand-off report
    • Occurs with transfer of patient care
    • Provides continuity and individualized care
    • Reports are quick and efficient.
  113. Telephone reports and orders
    • Situation-background-assessment-recommendation(SBAR)
    • Document every call
    • Read back
  114. Incident or occurrence reports
    • Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient
    • Follow agency policy
  115. Health Informatics
    • Application of computer and information science for managing health-related data
    • Focus on the patient and the process of care
    • Goal is to enhance the quality and efficiency of care provided.
    • Driven by the Health Information Technology forEconomic and Clinical Health Act (HITECH)
  116. NISs
    Nursing Information Systems
  117. Advantages of NISs
    • Increased time to spend with patients
    • Better access to information
    • Enhanced quality of documentation
    • Reduced errors of omission
    • Reduced hospital costs
    • Increased nurse job satisfaction
    • Compliance with accrediting agencies
    • Common clinical database development
  118. A hospital information system consists of two major types of information systems:
    • Clinical Information Systems  (CISs) and
    • administrative information systems.
  119. CIS =
    • Monitoring systems,
    • order entry, and
    • laboratory,
    • radiology, and
    • pharmacy systems
  120. Computerized provider order entry (CPOE)
    • Improves accuracy
    • Speeds implementation
    • Improves productivity
    • Saves money
  121. What is Critical Thinking ?
    • A continuous process characterized by open-­
    • mindedness, continual inquiry, and perseverance, combined with a willingness to look at each unique patient situation and determine which identified assumptions are true and relevant
    • Recognizing that an issue exists, analyzing information, evaluating information, and making conclusions
  122. Components of Critical Thinking in
    • I. Specific knowledge base in nursing
    • II. Experience
    • III. Critical thinking competencies
    • IV. Attitudes for critical thinking
    • V. Standards for critical thinking
    • A. Intellectual standards
    • B. Professional standards
  123. Critical Thinking Skills 6
    • Interpretation
    • Analysis
    • Inference
    • Evaluation
    • Explanation
    • Self-­‐regulation
  124. Characteristics of a Critical
    • Truth seeking
    • Open-­‐mindedness
    • Analytic approach
    • Systematic approach
    • Self-­‐confidence
    • Inquisitiveness
    • Maturity
  125. Critical Thinking Competencies 6
    • Scientific method
    • Problem solving
    • Decision making
    • Diagnostic reasoning and inference
    • Clinical decision making
    • Nursing process as a competency
  126. Attitudes a Nurse Needs 11
    • Confidence
    • Independence
    • Fairness
    • Responsibility
    • Risk taking
    • Discipline
    • Perseverance
    • Creativity
    • Curiosity
    • Integrity
    • Humility
  127. Reflective Journaling:
    A tool used to clarify concepts throughreflection by thinking back or recallingsituations
  128. Concept Mapping:
    A visual representation of patient problems andinterventions that illustrates an interrelationship
  129. Caring for Groups of Patients
    • Identify the nursing diagnoses and collaborative problems of each patient. 
    • Decide which are most urgent. 
    • Consider the time it will take to care for those patients. 
    • Consider the resources that you have to manage each problem. 
    • Consider how to involve the patients as participants in care. 
    • Decide how to combine activities. 
    • Decide which nursing care procedures to delegate. 
    • Discuss complex cases with the health care team.
  130. The Nursing Process: A five-step clinical decision-making approach
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
  131. Assessment: First “step” in the Nursing Process

    Includes “2 steps”:
    • Collection of information from primary and secondary sources 
    • Interpretation and validation of data to ensure a completedatabase
  132. Purpose of assessment
    • establish database about patient’s perceived needs, health problems, and responses to problems
    • Data may also reveal related experiences, health practices, goals, values & expectations about health care
  133. Sources of data 6
    • Patient (interview, observation, physicalexamination)—the best source of information 
    • Family and significant others (obtain patient’sagreement first) 
    • Health care team 
    • Medical and other records 
    • Scientific literature 
    • Nurse’s experience
  134. Process of Assessment
    • Collect data. 
    • Cluster cues, make inferences, and identifypatterns and problem areas. 
    • Critically anticipate. 
    • Be sure to have supporting cues before making an inference. 
    • Knowing how to probe and frame questions is askill that grows with experience.
  135. Cultural Considerations
    • To conduct an accurate and complete assessment, you need to consider a patient’s cultural background. 
    • When cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patient’s uniqueness. 
    • If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion.
  136. Nursing Health History
    • Biographical information
    • Patient expectations
    • Reason for seeking health care
    • Present illness or health concerns
    • Health history
    • Family history
    • Environmental history
    • Psychosocial history
    • Spiritual health
    • Review of systems
    • Documentation of findings
  137. Data Documentation
    • The last component of a complete assessment
    • Legal and professional responsibility
    • Requires accurate and approved terminology and abbreviations
  138. 1. Medical diagnosis
    Identification of a diseasecondition based on specificevaluation of signs and symptoms
  139. 2. Nursingdiagnosis
    Clinical judgment about the patient in response to an actual or potential health problem
  140. 3. Collaborative problem
    Actual or potential physiological complication that nurses monitor to detect a change in patient status
  141. Nursing Diagnostic Statements 4
    • Provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding patients’ needs 
    • Allows nurses to communicate what they do among themselves and with other health care professionals and the public 
    • Distinguishes the nurse’s role from that of the physician or other health care provider 
    • Helps nurses focus on the scope of nursing practice
  142. Nursing Diagnostic Process
    • Assessment of patient’s health status:
    •    • Patient, family, and health care resources constitute database.
    •    • Nurse clarifies inconsistent or unclear information.
    •    • Critical thinking guides and directs line of questioning and examination to reveal detailed and relevant database.
    • Validate data with other sources.
    • Are additional data needed? If so, reassess.If not, continue...
    • Interpret and analyze meaning of data
    • Data clustering
    •    • Group signs and symptoms.
    •    • Classify and organize.
    • Look for defining characteristics and related factors.
    • Identify patient needs. 
    • Formulate nursing diagnoses and collaborative problems.
  143. A data cluster is
    • a set of signs or symptoms gathered during assessment that you group together in a logical way.
    • Data clusters are patterns of data that contain defining characteristics—clinical criteria that are observable and verifiable.
  144. clinical criterion is
    an objective orsubjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion.
  145. A related factor is
    • a condition, historical factor, or causative event that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis. 
    • A related factor allows you to individualize a nursing diagnosis for a specific patient.
  146. Actual NursingDiagnosis
    Describes human responses to health conditions or life processes
  147. Risk Nursing Diagnosis
    Describes human responses to health conditions/life processes that may develop
  148. Health Promotion Nursing Diagnosis
    A clinical judgment of motivation, desire, and readiness to enhance well-­‐being and actualize human health potential
  149. Components of Nursing Diagnosis(ND)
    • Diagnostic label
    • Related factors (etiology)
    • Defining characteristics
  150. Diagnostic label
    • Name of ND as approved by NANDA 
    • All have a definition which describes the characteristics of the human response identified (definition helps you ID the correct ND)
  151. Related factors (etiology)
    • Identified from patient assessment data; reason patientis displaying the ND 
    • Four categories – pathophysiological, treatment-­‐related, situational, and maturational
  152. Defining characteristics
    • Symptoms patient is manifesting
    • Used only with 3 part ND statements
  153. Sources of Diagnostic Error
    • • Data Collecting
    • • Data Clustering
    • • Interpreting/Analyzing
    • • Diagnostic statement (Labeling)
  154. Diagnostic Statement Guidelines 12
    • 1. Identify the patient’s response, not themedical diagnosis.
    • 2. Identify a NANDA-­‐I diagnostic statement ratherthan the symptom.
    • 3. Identify a treatable cause or risk factor rather thana clinical sign or chronic problem that is nottreatable through nursing intervention.
    • 4. Identify the problem caused by the treatment ordiagnostic study rather than the treatment or study itself.
    • 5. Identify the patient response to the equipment rather than the equipment itself.
    • 6. Identify the patient’s problems rather than your problems with nursing care.
    • 7. Identify the patient problem rather than the nursing intervention.
    • 8. Identify the patient problem rather than the goal of care.
    • 9. Make professional rather than prejudicial judgments.
    • 10. Avoid legally inadvisable statements.
    • 11. Identify the problem and its cause to avoid a circular statement.
    • 12. Identify only one patient problem in the diagnostic statement.
  155. Establishing Priorities
    • Ordering of nursing diagnoses or patient problems uses determinations of urgency and/or importance to establish a preferential order for nursing actions. 
    • Helps nurses anticipate and sequence nursing interventions
    • The order of priorities changes as a patient’s condition changes. 
    • Priority setting begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems. 
    • Patient-centered care requires you to know a patient’s preferences, values, and expressed needs. 
    • Ethical care is a part of priority setting.
  156. Patient-­‐centered goal:
    A specific and measurable behavior or response that reflects a patient’s highest possible level of wellness and independence in function
  157. Short-­‐term goal:
    An objective behavior or response expected within hours to a week
  158. Long-­‐term goal:
    An objective behavior or response expected within days, weeks, or months
  159. Goals of Care 3
    • Always partner with patients when setting their individualized goals.
    • For patients to participate in goal setting, they need to be alert and must have some degree of independence in completing activities of daily living, problem solving, and decision making.
    • Patients need to understand and see the value of nursing therapies, even though they are often totally dependent on you as the nurse.
  160. Seven Guidelines for Writing Goals
    • Patient centered
    • Singular goal or outcome
    • Observable
    • Measurable
    • Time limited
    • Mutual factors
    • Realistic
  161. Expected Outcomes
    • An objective criterion for goal achievement 
    • A specific, measurable change in a patient’s status that you expect in response to nursing care 
    • Direct nursing care 
    • Determine when a specific, patient-­‐centered goal has been met 
    • Are written sequentially, with time frames 
    • Usually, several are developed for each nursing diagnosis and goal.
  162. Critical Thinking in Planning Care Nurses need to:
    • Know the scientific rationale for the intervention
    • Possess the necessary psychomotor andinterpersonal skills 
    • Be able to function within a setting to use health care resources effectively
  163. Types of Interventions
    • Nurse initiated: Independent—Actions that a nurse initiates
    • Physician initiated: Dependent—Require an order from a physician or other health care professional
    • Collaborative: Interdependent—Require combined knowledge, skill, and expertise of multiple health care professionals
  164. Clarifying an Order
    • When preparing for physician-initiated or collaborative interventions, do not automatically implement the therapy, but determine whether it is appropriate for the patient. 
    • The ability to recognize incorrect therapies is particularly important when administering medications or implementing procedures.
  165. Selection of Interventions Six factors to consider:
    • Characteristics of nursing diagnosis
    • Goals and expected outcomes
    • Evidence base for interventions
    • Feasibility of the interventions
    • Acceptability to the patient
    • Nurse’s competency
  166. Systems for Planning Nursing Care 2
    • Nursing care plan  
    • Interdisciplinary care plan
  167. Nursing care plan
    • Nursing diagnoses, goals andexpected outcomes, and nursing interventions, anda section for evaluation findings so any nurse isable to quickly identify a patient’s clinical needsand situation
    • Reduces the risk for incomplete, incorrect, orinaccurate care
    • Changes as the patient’s problems and status change
  168. Interdisciplinary care plan
    Contributions from all disciplines involved in patient care.
  169. Change of Shift
    A critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions
  170. Change-­‐of-­‐shift report:
    • Communicates information from off going to on coming patient care personnel= “Nurse handoff” 
    • Focus your reports on the nursing care, treatments, and expected outcomes documented in the care plans.
  171. Critical Pathways
    • Critical pathways are patient care plans that provide the multidisciplinary health care team with activities and tasks to be put into practice sequentially. 
    • The main purpose of critical pathways is to deliver timely care at each phase of the care process for a specific type of patient.
  172. Concept Maps
    • Provide a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions 
    • Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help you make better clinical decisions in planning care 
    • Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information
  173. A nursing intervention is
    • any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes. 
    • Interventions include direct and indirect care measures aimed at individuals, families, and/or the community.
  174. Direct Care
    Treatments performed through interactions with patients
  175. Direct Care Examples:
    • -­‐Medication administration
    • -­‐Insertion of anintravenous (IV) infusion
    • -­‐Counseling during a time of grief
    • Activities of DailyLiving(ADLs)
    • Instrumental Activities of Daily Living (IADLs)
    • Physical care techniques
    • Lifesaving measures
  176. Indirect Care
    Treatments performed away from the patient but on behalf of the patient or group of patients
  177. Indirect Care Examples
    • -­‐Managing the patient’s environment (e.g., safety and infection control)
    • -­‐Documentation
    • -­‐Interdisciplinary collaboration
    • Communicating nursing interventions: Written or oral
    • Delegating, supervising, and evaluating the work of other health care team members
  178. Guidelines and Protocols
    Systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations
  179. Standing Orders
    A preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems
  180. Critical Thinking and Evaluation
    • Evaluation is an ongoing process.
    • If outcomes are met, patient goals are met. 
    • Positive evaluations occur when nurses meet desired outcomes. 
    • Positive evaluations lead nurses to conclude that interventions were successful.
  181. Standards for Evaluation: Nursing care helps patients:
    • Resolve actual health problems
    • Prevent potential problems
    • Maintain a healthy state
  182. Standards for Evaluation: American Nurses Association (ANA)
    Defines standards
  183. Standards for Evaluation:Competencies include:(5)
    • Being systematic
    • Using criterion-­‐based evaluation
    • Collaborating
    • Using ongoing assessment data to revise care plan
    • Communicating results
  184. Collaborate and Evaluate Effectiveness of Interventions (5)
    • Collaborate with the patient and family. 
    • Use evaluative measures.
    • Interpret and summarize findings. 
    • Document results. 
    • Revise care plan.
  185. Objective Evaluation 5
    • 1. Examine the outcome criteria.
    • 2. Evaluate the patient’s actual response.
    • 3. Compare the established outcome criteria withthe actual response.
    • 4. Judge the degree of agreement between the outcome criteria and the response.
    • 5. If no or only partial agreement, what are the barriers?
  186. Revising a Care Plan Discontinuing a care plan: 3
    • Has the goal been met?
    • Does the patient agree?
    • Document the discontinued plan.
  187. Revising a Care Plan Modifying a care plan:
    • Reassessment
    • Redefining diagnoses
    • Goals and expected outcomes
  188. Revising a Care Plan:Modifying a care plan: Interventions 3
    • Appropriateness of the intervention: Based on the standard of care
    • Correct application of the intervention
    • A patient’s nursing diagnoses, priorities, and interventions sometimes change as a result of evaluation.
  189. When a goal is not met, no matter what the reason:,
    repeat the entire nursing process sequence for that nursing diagnosis to identify necessary changes to the plan.
  190. Factors influencing Nutrition
    • Environment
    • Develop. needs
    • Drug-Nutrient Interactions
  191. Factors influencing Nutrition Developmental Needs Infants through school age"
    • Breastfeeding,
    • formula,
    • solid foods
  192. Factors influencing Nutrition Developmental Needs  Adolescents
    • Increased energy needs
    • Eating disorders
  193. Factors influencing Nutrition Developmental Needs  Young and middle adults
    • Pregnancy and lactation
    • Eating disorders
  194. Factors influencing Nutrition Developmental Needs Older adults
    • Decreased energy need
    • Financial concerns (food insecurity)
    • Illness related dietary needs
  195. Nursing Assessment Questions Nutrition 5
    • Dietary intake and food preferences
    • Unpleasant symptoms
    • Allergies
    • Taste, chewing, and swallowing
    • Appetite and weight
    • Use of medications
  196. Common Nursing Diagnoses Nutrition 7
    • Risk for aspiration
    • Deficient knowledge
    • Diarrhea
    • Imbalanced nutrition: less than body requirements
    • Imbalanced nutrition: more than body requirements
    • Feeding self-care deficit
    • Impaired swallowing
    • Readiness for enhanced nutrition
  197. Nutrition Implementation & Evaluation Acute care: 6
    • Interruptions
    • Advancing diets
    • Promoting appetite
    • Assisting with oral feeding
    • Enteral nutrition
    • Parenteral nutrition
  198. Nutrition Implementation & Evaluation:
     Health promotion
    • Dietary education
    • Meal planning
    • Weight loss support
    • Food safety
  199. Dysphagia
    difficulty swallowing
  200. Causes of Dysphagia
    • Myogenic- musclar (MD)
    • Neurogenic- MS/Stroke
    • Obstructive
    • Misc.
  201. S/S of Dysphagia 11
    • Cough when eating
    • Voice tone/quality change after swallowing
    • Abnormal movements of mouth, tongue or lips
    • Slow, weak, imprecise,uncoordinated speech
    • Abnormal gag
    • Delayed swallowing
    • Incomplete oral clearance (pocketing)
    • Regurgitation
    • Pharyngeal pooling
    • Delayed/absent trigger to swallow
    • Inability to speak
  202. Factors Affecting Oxygenation
    • Physiological factors
    • Conditions affecting chest wall movementChronic disease
  203. Factors Affecting Oxygenation Physiological factors:
    • Decreased oxygen-carrying capacity
    • Hypovolemia
    • Decreased inspired oxygen concentration Increased metabolic rate
  204. Factors Affecting Oxygenation Conditions affecting chest wall movement
    • Pregnancy
    • Musculoskeletal abnormalities
    • Trauma
    • Neuromuscular diseases
    • CNS alterations
  205. Alterations in Respiratory Function:Hyperventilation S/S
    – rapid respirations, sighing breaths, numbness &tingling of hands/feet, light-headedness, and loss ofconsciousness
  206. Alterations in Respiratory Function:
    CO2 removed faster than produced by cellularmetabolism
  207. Alterations in Respiratory Function: Hypoventilation
    Inadequate alveolar ventilation
  208. Alterations in Respiratory Function: Hypoventilation S/S
    – mental status change, dysrhythmia, potentialcardiac arrest…..convulsions, unconsciousness, death
  209. Alterations in Respiratory Function: Hypoxia
    • Inadequate tissue oxygenation at cellular level
    • Life-threatening
  210. Alterations in Respiratory Function: Hypoxia S/S
    – apprehension, restlessness, inability to concentrate, dizziness, behavioral changes, fatigued & agitated, cannot lay flat, increased pulse rate, increased rate/depth respirations…may see increased BP early
  211. Alterations in Respiratory Function: Hypoxia Later S/S
    • – respiratory rate declines, cyanosis
    • Central cyanosis versus peripheral cyanosis
  212. Factors Influencing Oxygenation Lifestyle factors:
    • Nutrition
    • Exercise
    • Smoking
    • Substance abuse
    • Stress
  213. Respiratory Assessment Questions
    • Nature of cardiopulmonary problem
    • Signs and symptoms
    • Onset and duration
    • Severity
    • Predisposing factors
    • Effect of symptoms on patient
  214. Respiratory Nursing History Components 11
    • Pain
    • Fatigue
    • Dyspnea
    • Cough
    • Wheezing
    • Environmental or geographical exposures
    • Smoking
    • Respiratory infections
    • Allergies
    • Health risks
    • Medications
  215. Respiratory Physical Examination
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
    • Diagnostic tests
  216. Respiratory Common Age – Related Changes: Heart (4)
    • Muscle contraction
    • Blood flow
    • Conduction system
    • Arterial vesselcompliance
  217. Respiratory Common Age – Related Changes: Lungs
    • Mechanics of breathing
    • Oxygenation
    • Breathing control/pattern
    • Lung defenses
    • Sleep and breathing
  218. Abnormalities in Cardiopulmonary System upon Inspection
    • Xanthelasma
    • Corneal arcus
    • Pale conjunctiva
    • Cyanotic conjunctiva
    • Petechiae on conjunctiva
    • Cyanotic mucus membranes
    • Pursed-lip breathing
    • Neck vein distention
    • Nasal flaring
    • Retractions
    • Chest asymmetry
    • Skin cyanosis –peripheral vs. central
    • Decreased skin turgor
    • Dependent edema
    • Periorbital edema
    • Clubbing
    • Splinter hemorrhages
    • Nail bed cyanosis
  219. Respiratory Health Promotion Strategies
    • Vaccinations
    • Lifestyle considerations
    • Pollutants
    • Teaching strategies
  220. Respiratory Acute Care Management
    • Interventions for dyspnea
    • Airway maintenance
    • Secretions
    • Hydration
    • Humidification
    • Nebulization
    • Oxygen
    • Breathing exercises
    • Coughing and deep breathing
    • Chest physiotherapy
    • Postural drainage
    • Suctioning
    • Airways
    • Promoting airway expansion
  221. Home Oxygen Therapy: Indications
    O2 saturation
    PaO2 < 55mmHgO2 saturation < 88% on room air