Nursing Process/surgical patients NUR106

Home > Flashcards > Print Preview

The flashcards below were created by user rmwartenberg on FreezingBlue Flashcards. What would you like to do?

  1. Nursing process
    treatment of HUMAN RESPONSES key word for exam.
  2. Nurses
    • advocate 
    • promote healing-safety
    • challange status quo
  3. Human responses
    • reactions to an event or disease-everyone will react differently.
    • MI
    • physical-pain
    • psychosocial-fear of death
    • sociocultural-concerns about returning to work
    • spiritual response-bargaining with god..
  4. Human responses occur at different levels?
    • cellular
    • system
    • whole person
  5. knowledge base
    • physical/behavioral sciences
    • repertoire of intellectual, interpersonal and technical skills.
  6. OSBN nursing process
    systematic method RN use when providing care, assessing, nursing diagnoses, planning, intervening and evaluating.
  7. ANA
    • defines nursing process
    • authoritative statements
  8. 6 steps nursing process
    • assessing: systemic collection of data
    • diagnosis: data analysis, bases on present illness, problem identification, formulate nursing diagnosis
    • outcome identification: what the pt. is expected to acheive
    • planning: holistic plan of care-to achieve outcomes. 
    • implementation: execute nursing care plan
    • evaluation: Pt level of outcome achievement
  9. Test question tip
    Assume the pt. is in perfect health unless they state otherwise in the question
  10. PN vs RN
    RN does everything a PN will do in regards to a focussed assessment, but will go through a comprehensive assessment as well -extensive collection and analysis of data for assessment. Holistic approach
  11. Holistic model
    • physiological
    • psychological
    • developmental
    • cultural 
    • sexual
    • spiritual
    • economic
    • learning
  12. nursing diagnosis
    educated and licensed to make nursing diagnoses: describes a patient (individual, family, or group) response to an actual or potential health problem.
  13. diagnosis steps
    • data analysis
    • problems ID
    • diagnostic labeling
    • prioritization
  14. problem identification
    My patient is....
  15. diagnostic labeling
    • NANDA label component-
    • Label/stem
    • related factors-contribute to the primary problem
    • defining characteristics-manifested by S&S associated with diagnosis
  16. Actual nursing diagnosis
    • 1. problem 
    • 2. etiology
    • 3. S&S
  17. Etiology
    • brief discription of the probably cause of the main problem-
    • holistic approach
  18. S&S
    The proof for the nursing diagnosis-problems, etiology
  19. Impaired skin integrity nursing diagnosis
    • Related to-etiology-physical immobility, low O2 sat, incontinence
    • S&S-manifested by disruption of the skin surface, bed rest, urinary incontinence and absent breath sounds in RL lung field, productive cough, with thick green mucous, RR-25, SA02 of 88%
  20. Ineffective airway clearance
    • eitology: increased production of secretion and increased viscosity secondary to pneumonia
    • Manifested-S&S: course crackles, all lung fields, productive cough w/ thick green expectorant, increased RR >20
  21. Priority in the nursing process- Maslows Hierarchy of needs
    Priority One: Physiological Needs◦Problems interfering with ability to be free of offensive stimuli.–Pain, nausea, physical irritation
  22. Maslows Priority 2
    • Priority Two: Safety and Security Needs◦
    • Problems posing a threat to safety and security.–Anxiety, fear, environmental hazards, physical activity deficits, violence toward self or others, knowledge deficit
  23. Maslows priority 3
    • Priority Three: Love and Belonging Needs◦
    • Problems posing a threat to feeling loved and a part of something.–Loss of a loved one, sensory-perceptual losses, inability to maintain family and significant other relationships, isolation
  24. Maslows priority 4
    Priority Four: Self-Esteem Needs◦Problems posing a threat to self-esteem.–Inability to perform activities of daily living, change in structure or function of a body part
  25. Maslows priority 5
    Priority Five: Self-Actualization Needs◦Problems posing a threat to the ability to achieve personal goals.–Inability to return to school, negative personal assessment of life events
  26. Outcome Ineffectve airway clearance
    Nursing expected outcome: The Patient will have clear airways throughout all lung fields by discharge as evidence by absence of crackles, productive cough and respiratory rate less 20.
  27. Outcomes expected
    • ◦Subject: The patient will…
    • ◦Verb: Measurable action–For example: Identify, Describe, Discuss, Relate, State, List, Verbalize, Demonstrate, Has an absence of, Perform, Walk, Stand, Sit
    • –Samples of Non-measurable verbs: know, understand, appreciate, think, accept, feel–Example: “clear airways”
  28. Nursing diagnosis example
    Impaired gas exchange related to infectious exudate and fluids in the airways of the lung secondary to pneumonia manifested by respiratory rate > 20, can only speak 3-4 words before gasping for a breath, unable to lay flat, pulse oximeter readings 88%, productive cough with bright green expectorant.
  29. Test tip in regards to the treatments of a patient
    Assume that nothing has been done unless they tell you it has.
  30. PARQ Conference with patient
    • Procedure
    • Alternative treatments
    • Risks of procedure
    • Questions
  31. Informed consent
    • Married at 16
    • Emancipated minor
    • any 15 year old or older may consent for hospital care, medical diagnosis, dental daignosis/treatment, surgical diagnosis/treatment, providers may advise parents about care, treatment, diagnosis.
  32. drains and time frames
    • Sansuinous onset-24
    • serosanguinous 24-72
    • serous over 72 hours. 
    • anything other than red/pink it's more likely purulent.
  33. Consent is always prefered, but not required for treatment
    • family member may give consent over the phone-must have 2 witnesses 
    • two physicians may provide authorization if POA unavailable.
    • court can appoint a legal guardian-when no family available
    • patients who cannot sign can sign an X must be witnessed by 2 providers
    • ESL must have certified interpreter.

Card Set Information

Nursing Process/surgical patients NUR106
2015-12-20 16:57:13
Nursing process
Show Answers:

What would you like to do?

Home > Flashcards > Print Preview