Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
189 Cards in this Set
- Front
- Back
NURSING PROCESS
|
A SYSTEMATIC PROCESS THAT IS RATIONAL, CONTINUOUS, CYCLICAL AND DYNAMIC, GOAL-ORIENTED, CLIENT CENTERED AND INTERPERSONAL, COLLABORATIVE AND UNIVERSALLY APPLICABLE
|
|
FIVE STEPS OF THE NURSING PROCESS
|
ASSESSMENT, DIAGNOSIS OR ANALYSIS, PLAN, IMPLEMENT AND EVALUATE
|
|
ASSESSMENT PURPOSE
|
TO ESTABLISH A DATABASE ABOUT THE CLIENTS RESPONSE TO HEALTH CONCERNS OR ILLNESS AND THE ABILITY TO MANAGE HEALTH CARE NEEDS
|
|
HOW TO ESTABLISH A DATABASE
|
OBTAIN A NURSING HEALTH HISTORY CONDUCT A PHYSICAL ASSESSMENT REVIEW CLIENT RECORDS REVIEW NURSING LITERATURE CONSULT SUPPORT PERSONS
CONSULT HEALTH PROFESSIONALS -UPDATE DATA AS NEEDED -VALIDATE DATA -COMMUNICATE/DOCUMENT DATA |
|
PURPOSE OF DIAGNOSING
|
TO IDENTIFY CLIENT STRENGTH AND HEALTH PROBLEMS THAT CAN BE PREVENTED OR RESOLVED BY COLLABORATIVE AND INDEPENDENT NURSING INTERVENTIONS. TO DEVELOP A LIST OF NURSING DIAGNOSIS AND COLLABORATIVE PROBLEMS. INTERPRET AND ANALYZE DATA
|
|
STEPS TO INTERPRET AND ANALYZE DATA FOR DIAGNOSING
|
COMPARE DATA AGAINST STANDARDS
CLUSTER OR GROUP DATA (GENERATE TENTATIVE HYPOTHESIS) IDENTIFY GAPS OR INCONSISTENCIES DETERMINE CLIENTS STRENGTHS, RISKS, AND PROBLEMS FORMULATE NURSING DIAGNOSIS AND COLLABORATIVE PROBLEM STATEMENTS |
|
PURPOSE OF PLANNING
|
TO DEV ELOPE AN INDIVIDUALIZED CARE PLAN THAT SPECIFIES CLIENT GOALS/DESIRED OUTCOMES AND RELATED NURSING INTERVENTIONS
SET PRIORITIES AND GOAL/ OUTCOMES IN COLLABORATION WITH THE CLIENT |
|
STEPS OF PLANNING
|
WRITE GOALS/ DESIRED OUTCOMES
SELECT NURSING STRATEGIES/ INTERVENTIONS CONSULT OTHER HEALTH PROFESSIONALS WRITE NURSING ORDERS AND NURSING CARE PLAN COMMUNICATE CARE PLAN TO RELEVANT HEALTH CARE PROVIDERS |
|
PURPOSE OF IMPLEMENTING
|
TO ASSIST THE CLIENT TO MEET DESIRED GOALS/OUTCOMES; PROMOTE WELLNESS; PREVENT ILLNESS AND DISEASE; RESTORE HEALTH; AND FACILITATE COPING WITH ALTERED FUNCTIONING
REASSESS THE CLIENT TO UPDATE DATABASE |
|
STEPS OF IMPLEMENTING
|
DETERMINE NEED FOR NURSING ASSISTANCE
PERFORM OR DELEGATE PLANNED NURSING INTERVENTION COMMUNICATE WHAT NURSING ACTIONS WERE IMPLEMENTED DOCUMENT CARE AND CLIENT RESPONSE TO CARE GIVE VERBAL REPORTS AS NECESSARY |
|
PURPOSE OF EVALUATING
|
TO DETERMINE WHETHER TO CONTINUE, MODIFY, OR TERMINATE THE PLAN OF CARE
COLLABORATE WITH CLIENT AND COLLECT DATA RELATED TO DESIRED OUTCOMES |
|
STEPS TO EVALUATING
|
JUDGE WHETHER GOALS/ OUTCOMES HAVE BEEN ACHIEVED
RELATE NURSING ACTIONS TO CLIENT OUTCOMES MAKE DECISIONS ABOUT PROBLEM STATUS REVIEW AND MODIFY THE CARE PLAN AS INDICATED OR TERMINATE NURSING CARE |
|
STANDARDS OF CARE
|
AUTHORITATIVE STATEMENTS THAT DESCRIBE A COMMON OR ACCEPTABLE LEVEL OF CLIENT CARE OF PERFORMANCE. STANDARDS OF CARE DEFINE PROFESSIONAL PRACTICE.
|
|
ASSESSMENT
|
SYSTEMIC COLLECTION VERIFICATION, ORGANIZATION, INTERPRETATION AND DOCUMENTATION OF DATA TO ESTABLISH A DATABASE
|
|
TYPES OF ASSESSMENT
|
FOCUSED
ONGOING COMPREHENSIVE |
|
TYPES OF DATA
|
PRIMARY
SECONDARY SUBJECTIVE OBJECTIVE HEALTH HISTORY |
|
DIAGNOSIS OR ANALYSIS
|
ANALYSIS OR SYNTHESIS OF DATA TO IDENTIFY THE PT'S ACTUAL OR POTENTIAL NURSING DIAGNOSIS
DATA IS ANALYZED AND NURSING DX. IS IDENTIFIED DIAGNOSTIC STATEMENTS ARE WRITTEN |
|
NURSING DIAGNOSIS
|
FIRST ACTUAL NURSING DX. IS THE PROBLEM STATEMENT OR DIAGNOSING LABEL
|
|
THREE CATEGORIES OF NURSING DIAGNOSIS
|
ACTUAL
RISK WELLNESS |
|
PRIORITIES ACCORDING TO MASLOW'S HIERARCHY OF NEEDS
|
1. PHYSIOLOGICAL
2. SAFETY AND SECURITY 3. LOVE AND BELONGING 4. SELF ESTEEM 5. SELF ACTUALIZATION |
|
COMPONENTS OF NURSING DX.
|
1. ACTUAL NURSING DX. OR PROBLEM STATEMENT
2. ETIOLOGY THAT IS R/T THE CAUSE OR CONTRIBUTOR 3. DEFINING CHARECTERISTICS OR S/S SUBJECTIVE DATA OR CLINICAL MANIFESTATION - DX. IS VALIDATED |
|
PLANNING OR OUTCOME IDENTIFICATION INCLUDES:
|
1. GUIDELINES TO ESTABLISH A COURSE FOR NURSING ACTION TO RESOLVE NURSING DX
2. DEVELOPMENT OF A PLAN OF CARE |
|
PURPOSE OF PLANNING
|
1. PRIORITIZE PROBLEMS OF DIAGNOSIS
2. ESTABLISH GOALS AND EXPECTED OUTCOMES 3. TO DEVELOP PLAN OF CARE THROUGH GOALS ACHIEVED FROM NURSING INTERVENTIONS 4. TO ESTABLISH OUTCOME CRITERIA USED TO EVALUATE IF GOALS ARE MET 5. TO DELEGATE NURSING ACTIVITIES TO APPROPRIATE HEALTH CARE TEAM MEMBERS |
|
THREE PHASES OF NURSING CARE
|
1. INITIAL PLANNING
2. ONGOING PLANNING 3. DISCHARGE PLANNING |
|
INITIAL PLANNING
|
DEVELOPMENT OF PRELIMINARY PLAN OF CARE
|
|
ONGOING PLANNING
|
CONTINUOUS UPDATING OF THE PLAN OF CARE
|
|
DISCHARGE PLANNING
|
PLANNING OF PT'S NEEDS AFTER DISCHARGE
|
|
WHERE DOES OUTCOME IDENTIFICATION COME FROM
|
GOALS AND EXPECTED OUTCOMES FOR EACH NURSING DIAGNOSIS
|
|
GOALS
|
BROAD STATEMENTS THAT DESCRIBE THE INTENDED OR DESIRED CHANGE IN THE CLIENTS CONDITION
|
|
EXPECTED OUTCOMES
|
IDENTIFIED AFTER GOALS ESTABLISHED
MORE SPECIFIC THAN GOALS REALISTIC AND MEASURABLE |
|
WHEN CAN NURSING INTERVENTIONS BE FORMULATED
|
AFTER GOALS AND EXPECTED OUTCOMES ARE ESTABLISHED
|
|
TYPES OF NURSING INTERVENTIONS
|
INDEPENDENT
INTERDEPENDENT DEPENDENT |
|
INDEPENDENT NURSING INTERVENTION
|
ACTIONS THAT NURSE INITIATES
|
|
INTERDEPENDENT NURSING INTERVENTIONS
|
ACTIONS THAT ARE IMPLEMENTED IN COLLABORATION WITH OTHER HEALTH CARE PROFESSIONALS
|
|
DEPENDENT NURSING INTERVENTIONS
|
ACTIONS THAT REQUIRE AND ORDER BY A PHYSICIAN OR ANOTHER HEALTH CARE PROFESSIONAL.
|
|
NURSING CARE PLAN
|
ORGANIZED FORMAL STATEMENTS OF STRATEGIES THAT WILL BE IMPLEMENTED AND IS WRITTEN IN A PLAN
|
|
PROTOCOL
|
A SERIES OF STANDING ORDERS OR PROCEDURES THAT SHOULD BE FOLLOWED UNDER CERTAIN CONDITIONS
|
|
NURSING PRACTICE ACT
|
A STATUTE THAT IS ENACTED BY THE LEGISLATURE OF A STATE AND OUTLINES THE SCOPE OF NURSING PRACTICE IN THAT STATE
|
|
AMERICAN NURSES ASSOCIATION (ANA)
|
HAS ESTABLISHED STANDARDS FOR NURSING PRACTICE AND EDUCATION TO IMPROVE THE QUALITY OF CARE
|
|
STANDARDS OF PRACTICE
|
MAY BE OUTLINED IN POLICY AND PROCEDURE MANUALS OF A FACILITY
|
|
IMPLEMENTING OR INTERVENING
|
INVOLVES THE EXECUTION OF THE NURSING CARE PLAN
|
|
REQUIREMENTS FOR IMPLEMENTATION
|
1. CONSTANT REASSESSMENT OF INTERVENTIONS TO SEE IF THEY ARE STILL NEEDED
2. ASSESSMENT OF CLIENT'S CONDITION BEFORE, AFTER, AND DURING Q INTERVENTION 3. DOCUMENT INTERVENTIONS AND RESPONSE 4. PROMOTE CONTINUITY OF CARE |
|
DELEGATION
|
PROCESS OF TRANSFERRING SELECTED NURSING TASKS TO LICENSED PERSONNEL WHO ARE COMPETENT
|
|
EVALUATION
|
INVOLVES DETERMINING WHETHER THE CLIENT GOALS HAVE BEEN MET, PARTIALLY MET OR NOT MET
|
|
VARIABLES AFFECTING OUTCOMES
REASONS GOALS AREN'T MET |
1. INITIAL ASSESSMENT INCOMPLETE
2. GOALS WEREN'T REALISTIC 3. TIME FRAME WAS INAPPROPRIATE 4. GOALS OR INTERVENTIONS WEREN'T APPROPRIATE |
|
WHO DEFINITION OF HEALTH
|
A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL BEING, NOT MERELY THE ABSENCE DISEASE OR INFIRMITY
|
|
HEALTH/WELLNESS CONTINUUM
|
THE RELATIONSHIP THAT DEPICTS HEALTH AND ILLNESS AS EXTREME ELEMENTS AT THE OPPOSITE STATUS POINTS ON THE LINE
|
|
HIGH LEVEL WELLNESS (PER HL DUNN)
|
CONCEPT THAT IS RELATED TO FAMILY, COMMUNITY, ENVIRONMENT AND SOCIETY
|
|
FAMILY WELLNESS ENHANCES __________
|
INDIVIDUAL WELLNESS
|
|
COMMUNITY WELLNESS ENHANCES _________
|
FAMILY ENVIROMENT
|
|
SOCIETY WELLNESS ENHANCES _____________
|
COMMUNITY
|
|
HEALTH BELIEF MODEL (ROSENSTOCK AND MODIFIED BY BECKER)
|
ASSUMED THAT GOOD HEALTH IS AN OBJECTIVE COMMON TO ALL PEOPLE AND IS ACHIEVED ON PERCEPTIONS OF SUSCEPTIBILITY, SERIOUSNESS, AND THREAT
|
|
AGENT - HOST ENVIRONMENT MODEL (ECOLOGIC MODEL) -LEVELL AND CLARK
|
PREDICTING ILLNESS BASED ON RISK FACTORS THAT RESULT FROM THE INTERACTIONS OF AGENT, HOST AND ENVIRONMENT. THESE FACTORS INTERACT IF IN BALANCE THEN HEALTH IS MAINTAINED IF NOT DISEASE OCCURS
|
|
AGENT
|
ANY ENVIRONMENT FACTOR OR STRESSOR THAT BY ITS PRESENCE OR ABSENCE CAN LEAD TO DISEASE
|
|
HOST
|
PERSON WHO MAY OR MAY NOT BE AT RISK FOR ACQUIRING DISEASE
|
|
ENVIRONMENT
|
IS ALL FACTORS EXTERNAL TO THE HOST THAT MAY PREDISPOSE THE PERSON TO DISEASE
|
|
STRESS
STIMULUS BASED |
DESCRIBE STRESS AS A DISRUPTION IN THE ENVIRONMENT OR WITHIN THE BODY
|
|
STRESS
LIFE CHANGE THEORY (HOLMES AND RAHE) |
STRESS OF LIFE IS DEFINED BY TERMS OF UNITS OF LIFE CHANGE
|
|
STRESS
DAILY HASSLES THEORY (LAZARUS) |
IS A TOOL TO MEASURE STRESS IN TERMS OF DAILY HASSLES RATHER THAN MAJOR LIFE EVENTS
|
|
STRESS
RESPONSE BASED (HANS SELYE) |
DEFINED STRESS AS A NONSPECIFIC RESPONSE TO ANY DEMAND MADE ON THE BODY. THESE DEMANDS ARE LABELED STRESSORS: THEY CAN BE EXTERNAL OR INTERNAL.
|
|
THE PERCEPTION OF THE STRESSOR IS WHAT DETERMINES ________________________
|
THE EFFECT IS POSITIVE OR NEGATIVE
|
|
GENERAL ADAPTION SYNDROME (GAS)
|
BODY ATTEMPTS TO MAINTAIN HOMEOSTASIS OF STRUCTURAL AND CHEMICAL CHANGES IN RESPONSE TO STRESSORS.
|
|
3 STAGES OF GENERAL ADAPTATION SYNDROME
|
1. CRISIS OR ALARM STAGE
2. RESISTANCE OR ADAPTION STAGE 3. EXHAUSTION STAGE |
|
CRISIS OR ALARM STAGE
|
CNS IS AROUSED AND PHYSIOLOGIC DEFENSE IS MOBILIZED- THE FIGHT OR FLIGHT RESPONSE
|
|
RESISTANCE OR ADAPTATION STAGE
|
THE FIGHT OR FLIGHT RESPONSE IS CARRIED OUT
|
|
EXHAUSTION STAGE
|
WHEN ATTEMPTS TO ADAPT ARE UNSUCCESSFUL. THE INDIVIDUALS ABILITY IS EXHAUSTED. DEATH MAY RESULT
|
|
STRESS
TRANSACTION BASED (LAZARUS AND FOLKMAN) |
ACTIVATION OF THE STRESS RESPONSE DEPENDS UPON THE MEANING OF THE ENVIRONMENTAL CHANGES TAKING PLACE
|
|
3 STRESS CHARACTERISTICS
|
PHYSICAL
PSYCHOLOGICAL SOCIAL |
|
PHYSICAL STRESSORS
|
TRAUMA, SURGERY, OXYGEN DEPRIVATION, FATIGUE, INFECTIOUS PROCESS, PAIN, SLEEP DEPRIVATION
|
|
PSYCHOLOGICAL STRESSORS
|
ANTICIPATING SURGERY, PAIN, HELPLESSNESS, POWERLESSNESS, LONELINESS, REJECTION, JOB LOSS
|
|
SOCIAL STRESSORS
|
POLLUTANTS, URBANIZATION, RELOCATION, POVERTY, LOSS OF PRIVACY, FAMILY PROBLEMS, CHILD REARING
|
|
STRESS
PHYSICAL SX. |
INCREASE PULSE AND B/P, RAPID SHALLOW BREATHING, DIZZINESS, HEADACHES, DILATED PUPILS, NAUSEA, ALTERED APPETITE, DIARRHEA OR CONSTIPATION, POLYURIA, TENSION AND TWITCHING
|
|
STRESS
PSYCHOLOGICAL SX. |
ANXIETY, FEAR, ANGER, AGGRESSION,DEFENSIVE BEHAVIOR WITH IRRITABILITY, SADNESS, DEPRESSION, INCREASED SENSITIVITY
|
|
STRESS
COGNITIVE SX. |
IMPAIRED MEMORY, CONFUSION, POOR DECISION MAKING, DELAYED RESPONSE TIME, ALTERED PERCEPTIONS, INABILITY TO CONCENTRATE
|
|
STRESS
BEHAVIOR SX. |
PACING, SWEATY PALMS, RAPID SPEECH, INSOMNIA, W/D AND EXAGGERATED STARTLE REFLEX
|
|
STRESS
SPIRITUAL SX. |
ALIENATION, SOCIAL ISOLATION, FEELINGS OF EMPTINESS
|
|
STRESS
ADAPTATION |
CONTINUOUS PROCESS IN WHICH INDIVIDUALS USE VARIOUS RESPONSES TO ADJUST TO STRESS
|
|
STRESS
PHYSIOLOGICAL |
BODY RESPONDS TO STRESS AFFECTING ITS FUNCTIONING.
MORE BLOOD CELLS INCREASED AIR TO LUNGS |
|
STRESS
PSYCHOLOGICAL |
USES DEFENSE SYSTEMS TO MENTALLY ACCEPT NEW SITUATIONS
THESES DEFENSE MECHANISMS MAY PROTECT INDIVIDUALS FOR A LIMITED PERIOD OF TIME BUT CAN BLOCK CHANGE AND GROWTH. FOR HEALTH RESOLUTION OF STRESS THESE DEFENSE MECHANISMS NEED TO BE REPLACED BY EFFECTIVE COPING STRATEGIES |
|
STRESS
REPRESSION |
PREVENTING STRESSFUL THOUGHTS AND FEELINGS FROM ENTERING THE THE CONSCIOUS
|
|
STRESS
REACTION FORMATION |
EXPRESSION OF A FEELING THAT IS THE OPPOSITE OF ONE'S REAL FEELING
|
|
STRESS
SUPPRESSION |
AN ATTEMPT TO KEEP UNPLEASANT MATERIAL OUT OF CONSCIOUSNESS
|
|
STRESS
SUBLIMINATION |
DISPLACEMENT OF ENERGY ASSOCIATED WITH MORE AGGRESSIVE DRIVES INTO SOCIALLY ACCEPTABLE ACTIVITIES
|
|
STRESS
DENIAL |
AVOIDING THE THREAT OF A STRESSOR BY REINTERPRETING THE EVENT AS SOMETHING LESS THREATENING
|
|
STRESS
DISPLACEMENT |
THE TRANSFERRING OR DISCHARGING OF EMOTIONAL REACTIONS FROM ONE OBJECT OR PERSON TO ANOTHER OBJECT OR PERSON
|
|
STRESS
REGRESSION |
REVERTING TO LESS MATURE BEHAVIOR
|
|
STRESS
RATIONALIZATION |
INTELLECTUAL EXPLANATION OR JUSTIFICATION OF IDEAS FEELINGS OR BEHAVIOR
|
|
STRESS
PROJECTION |
ATTRIBUTION OF ONE'S OWN THOUGHTS, FEELINGS OT IMPULSES OF OTHERS
|
|
STRESS
UNDOING |
AN ACTION OR WORDS DESIGNED TO CANCEL SOME DISAPPROVED THOUGHTS IMPULSES OR ACTS IN WHICH THE PERSON RELIEVES GUILT BY MAKING REPARATION
|
|
COPING WITH STRESS
|
COPING STRATEGY IS AN INNATE OR ACQUIRED WAY OF RESPONDING TO A CHANGING ENVIRONMENT OR SPECIFIC PROBLEM OR SITUATION
|
|
LAZARUS AND FOLKMAN DEFINE COPING AS
|
INDIVIDUALS ATTEMPTS TO MASTER CONDITIONS OF HARM THREAT OR CHALLENGE WHEN AN AUTOMATIC RESPONSE IS NOT IMMEDIATELY AVAILABLE
|
|
MODES OF COPING
|
EMOTION FOCUSED
PROBLEM FOCUSED |
|
EMOTION-FOCUSED COPING
|
INCLUDES THOUGHTS AND AND ACTIONS THAT RELIEVE EMOTIONAL DISTRESS. DOESN'T IMPROVE THE SITUATION BUT THE PERSON FEELS BETTER
|
|
PROBLEM- FOCUSED COPING
|
EFFORTS TO IMPROVE A SITUATION BY MAKING CHANGES OR TAKING SOME ACTION.
(NEUTRALIZES STRESSOR) |
|
ANXIETY
|
A STATE OF MENTAL UNEASINESS APPREHENSION DREAD OR FOREBODING, OR A FEELING OF HELPLESSNESS R/TAN IMPENDING OR ANTICIPATED UNIDENTIFIED THREAT TO SELF OR SIGNIFICANT RELATIONSHIPS. IT IS A SUBJECTIVE RESPONSE THAT OCCURS WHEN A PERSON EXPERIENCES A REAL OR PERCEIVED THREAT TO WELL BEING
|
|
MILD ANXIETY
|
INCREASED DEGREE OF ALERTNESS AND VIGILANCE, MOTIVATION, VITAL SIGNS,
OPTIMAL TIME FOR CLIENT TEACHING |
|
MODERATE ANXIETY
|
SUBJECTIVE DISTRESS OR TENSION, DECREASED PERCEPTION AND ATTENTION
ALERT ONLY TO SPECIFIC INFORMATION POSSIBLE TENDENCY TO COMPLAIN OR ARGUE POSSIBLE HEADACHE, DIARRHEA, NAUSEA OR VOMITING |
|
SEVERE ANXIETY
|
INCREASED SUBJECTIVE DISTRESS, FEELINGS OF IMPENDING DANGER, SELECTIVE ATTENTION, DISTORTED COMMUNICATION, FEELINGS OF FATIGUE
|
|
PANIC
|
MAJOR PERCEPTUAL DISTORTION
IMMOBILIZATION INABILITY TO FUNCTION FEELINGS OF TERROR POSSIBLE HARM TO SELF AND OTHERS |
|
HEALTH PROMOTION AND MAINTENANCE
|
THE MAINTENANCE OR IMPROVEMENT OF EXISTING SELF CARE BEHAVIORS
|
|
PRIMARY HEALTH PROMOTION
|
GENERALIZED HEALTH PROMOTION AND SPECIFIC PROTECTION AGAINST DISEASE
|
|
SECONDARY HEALTH PROMOTION
|
EARLY IDENTIFICATION OF HEALTH PROBLEMS AND PROMPT INTERVENTION TO ALLEVIATE HEALTH PROBLEMS
|
|
TERTIARY HEALTH MAINTENANCE
|
RESTORATION AND REHABILITATION TO AN OPTIMAL LEVEL OF FUNCTIONING
|
|
HEALTH PROMOTION AND ILLNESS PREVENTION
PRIMARY CARE AGENCIES |
HEALTH PROMOTION, PREVENTIVE CARE, HEALTH EDUCATION, ENVIRONMENTAL PROTECTION, EARLY DETECTION AND TX.
EX: PUBLIC HEALTH, PHYSICIANS OFFICE, AMBULATORY CARE CENTER |
|
ILLNESS PREVENTION
SECONDARY CARE AGENCIES |
DEDICATED TO DX. AND TX OF ILLNESS
EX. HOSPITALS, PHYSICIANS OFFICE, CLINICS |
|
REHABILITATION
TERTIARY CARE |
PROCESS OF RESTORING ILL OR INJURED PEOPLE TO OPTIMUM AND FUNCTIONAL LEVELS OF WELLNESS
EMPHASIZE IMPORTANCE OF ASSISTING CLIENTS TO FUNCTION ADEQUATELY IN PHYSICAL, MENTAL, SOCIAL, ECONOMIC, VOCATIONAL AREAS OF THEIR LIVES EX: LTC, CARE OF THE DYING, REHABILITATION |
|
medical asepsis- clean technique
|
hand washing, gloving, and gowning, and disinfecting help contain microbial growth and prevent spread of organisms from one place to another
|
|
STANDARD PRECAUTIONS
|
WASH HANDS, WEAR CLEAN GLOVES, MASK, EYE PROTECTION, COVER GOWN
|
|
TRANSMISSION BASED PRECAUTIONS
|
FOR HIGHLY TRANSMISSIBLE
|
|
AIRBORNE
|
MICROORGANISMS THAT CAN BE SUSPENDED IN AIR; NEGATIVE AIRFLOW ROOM
|
|
DROPLET
|
LARGER PARTICLES. WEAR MASK IF WITHIN THREE FEET OF CLIENT
|
|
CONTACT
|
HAND TO SKIN CONTACT
|
|
BACTERICIDAL
|
KILLS MICROORGANISMS
|
|
BACTERIOSTATIC
|
PREVENTS MULTIPLICATION OF BACTERIA
|
|
SURGICAL ASEPSIS
|
STERILE TECHNIQUE
EX: IV INSERTION, CATH, INJECTIONS, DRESSING CHANGES, IRRIGATION OF TUBES THAT ENTER STERILE PARTS OF BODY FOR IMMUNE CAPABILITY: PRETERM BABY, BURN PT. , TRANSPLANT CLIENT, CHEMO, RADIATION, AIDS |
|
STERILIZATION
|
STEAM OR AUTOCLAVE
GAS (ETHYLINE OXIDE) USED WHEN STEAM CANT BE BUT IS EXPENSIVE AND TAKES LONGER |
|
STERILE FIELD
|
AREA FREE OF MICROORGANISMS, ANYTHING OUTSIDE OF VISUAL FIELD SHOULD BE CONSIDERED CONTAMINATED
|
|
CHAIN OF INFECTION
|
INFECTIOUS AGENT
RESERVOIR PORTAL OF EXIT TRANSMISSION PORTAL OF ENTRY SUSCEPTIBLE HOST |
|
INFECTIOUS AGENT
|
BACTERIA, VIRUS, FUNGUS OR PARASITE
|
|
RESERVOIR
|
SOURCE OF ORGANISMS
|
|
PORTAL OF EXIT
|
MEANS BY WHICH THE MICROORGANISM LEAVES THE SOURCE
EX: SPUTUM, EMESIS, BLOOD, STOOL, URINE, WOUND DRAINAGE, GENITALIA SECRETIONS |
|
MODES OF TRANSMISSION
|
AIRBORNE
CONTACT- MOST FREQUENT DIRECT- ONE BODY SURFACE TO ANOTHER INDIRECT- CONTAMINATED OBJECT (FOMITE) VEHICLE TRANSMISSION- TRANSFER. OF INFECTION BY WAY OF CONTAMINATE ITEMS |
|
DROPLET
|
MUCOUS MEMBRANES ARE EXPOSED TO COUGH, SNEEZE OR TALKING
|
|
VECTOR
|
ANIMAL OR INSECT THAT SERVES AS A INTERMEDIATE MEANS OF TRANSPORTING INFECTION
|
|
PORTAL OF ENTRY
|
MEANS BY WHICH THE MICROORGANISMS ENTER THE SOURCE
|
|
SUSCEPTIBLE HOST
|
ANY PERSON AT RISK FOR INFECTION
|
|
3 STAGES OF INFLAMMATORY RESPONSE
|
1. VASCULAR AND CELLULAR RESPONSE
2. EXUDATE PRODUCTION 3. REPARATIVE PHASE |
|
5 STAGES OF INFLAMMATION
|
1. INITIAL INJURY-CAUSES RELEASE OF HISTAMINE, BRADYKININ, SEROTONIN, PROSTOGLANDINS, AND LYMPHOKINES. THEY ALL ACTIVATE THE INFLAMMATION PROCESS
2. INCREASED BLOOD FLOW TO THE INFLAMED AREA- ERETHMA CAUSES REDNESS AND WARMTH 3. INCREASED CAPILLARY PERMEABILITY- LEAKAGE OF PLASMA CAUSING FIBROGEN CLOTS TO BLOCK LYMPHATICS AND RESULTS INTO NON PITTING EDEMA 4. DAMAGED TISSUE IS ENGULFED BY LEUKOCYTES. THEY DIE AND CAUSE PUS 5. DESTROYED TISSUE IS REPLACED BY SIMILAR TISSUE TO PROMOTE HEALING OR SCAR TISSUE FORMS |
|
SIGNS OF INFLAMMATION OR INFECTION
|
1. ERYTHEMA OR REDNESS FROM INCREASED BLOOD FLOW 2. HEAT FROM INCREASED BLOOD FLOW AND METABOLISM 3. PAIN FROM ^ PRESSURE ON PAIN SENSORS 4. EDEMA FROM ^ FLUID AND LEUKOCYTES 5. LOSS OF FUNCTION FROM PAIN AND EDEMA 6. PUS FROM WBC,DEAD CELLS, BACTERIA AND OTHER DEBRIS
|
|
SIGNS OF SYSTEMIC INFLAMMATION OR INFECTION
|
1. GENERAL MALAISE 2. FEVER COMMON BUT NOT ALWAYS PRESENT 3. MYALGIA AND ARTHRALGIA 4. NONSPECIFIC GI SX. 5. INCREASED WBC 6. CHILLS OR SWEATS
|
|
ANTIGENS
|
SUBSTANCE CAPABLE OF INDUCING FORMATION OF ANTIBODIES- FOREIGN PROTEINS IN THE BODY
|
|
ANTIBODIES
|
IMMUGLOBULIN
A PROTECTIVE PROTEIN SUBSTANCE PRODUCED IN THE BODY TO COUNTERACT ANTIGENS |
|
IMMUNITY
|
SPECIFIC RESISTANCE OF THE BODY TO INFECTION
|
|
2 TYPES OF IMMUNITY
|
ACTIVE AND PASSIVE
|
|
ACTIVE IMMUNITY
|
HOST PRODUCES IT'S OWN ANTIBODIES IN RESPONSE TO NATURAL ANTIGENS (INFECTION) OR ARTIFICIAL INFECTIONS (VACCINES)
|
|
PASSIVE IMMUNITY
|
THE HOST RECEIVES NATURAL (NURSING MOTHER) OR ARTIFICIAL (INJECTION OF IMMUNE SERUM) ANTIBODIES PRODUCED BY ANOTHER SOURCE
|
|
ANTIBODY - MEDIATED DEFENSES
|
HUMORAL (CIRCULATING) IMMUNITY
RESIDES IN B LYMPHOCYTES AND MEDIATED BY ANTIBODIES PRODUCED BY B LYMPHOCYTES |
|
STEPS OF MEDIATED DEFENSES
|
1. B CELLS ARE ACTIVATED AND RECOGNIZE A FOREIGN INVADER OR ANTIGEN
2. THEY THEN DIFFERENTIATE INTO PLASMA CELLS WHICH SECRETE ANTIBODIES 3. THE ANTIBODIES INITIATE A VARIETY OF ELIMINATION PROCESSES 4. Ig M, G, A , D, E IgM SHOWS A CURRENT INFECTION IgG INDICATES A PAST INFECTION |
|
CELL MEDIATED DEFENSES
|
CELLULAR IMMUNITY THROUGH THE T CELL SYSTEM
|
|
STEPS OF CELL MEDIATED DEFENSES
|
1. WHEN EXPOSED THE LYMPHS RELEASE A LARGE # OF T CELLS BECAUSE OF THE RELEASE OF LYMPHOKINES THAT ATTRACT OTHER PHAGOCYTES AND LYMPHOCYTES
T CELLS ALSO STIMULATE THE PRODUCTION OF B CELLS |
|
3 TYPES OF T CELLS
|
1. T HELPER CELL- HELP IN FUNCTION OF IMMUNE SYSTEM
2. CYTOTOXIC T CELLS- SUPPRESS THE HELPER AND CYTOTOXIC CELLS 3. T CELLS ALSO STIMULATE THE PRODUCTION OF B CELLS |
|
STAGES OF INFECTIOUS PROCESS
|
1. INCUBATION PERIOD
2. PRODROMAL STAGE 3. ILLNESS 4. CONVALESCENT |
|
INCUBATION PERIOD
|
INTERVAL OF TIME BETWEEN ENTRY OF AN INFECTIOUS AGENT INTO THE BODY AND ONSET OF SYMPTOMS
|
|
PRODROMAL STAGE
|
PERIOD OF TIME FROM ONSET OF NONSPECIFIC SX UNTIL SPECIFIC SYMPTOMS MANIFEST
|
|
ILLNESS
|
PERIOD OF TIME WHEN THE CLIENT IS MANIFESTING SPECIFIC S/S
|
|
CONVALESCENT
|
PERIOD OF TIME FROM THE BEGINNING OF DISAPPEARANCE OF ACUTE SX UNTIL THE CLIENT RETURNS TO THE PREVIOUS STATE OF HEALTH
|
|
WOUND HEALING PHASES
|
1.INFLAMMATION-LASTS APPROX 3 DAYS
2.REGENERATION-AFTER INFLAMMATION PHASE DAY 4-21 3.MATURATION-FROM 3 WEEKS TO 2 YEARS |
|
WOUND HEALING TYPES
|
1. PRIMARY INTENTION
2. SECONDARY INTENTION 3. TERTIARY INTENTION |
|
PRIMARY INTENTION
|
OCCURS IN MINIMAL TISSUE LOSS, GRANULATION TISSUE IS NOT VISIBLE AND SCARRING IS MINIMAL, RISK FOR INFECTION IS LOW
EX: CLEAN SURGICAL EXCISION EDGES APPROXIMATED OR LIGHTLY PULLED TOGETHER |
|
SECONDARY INTENTION
|
OCCURS IN FULL THICKNESS TISSUE LOSS, OPEN WOUND GRADUALLY FILLS IN WITH GRANULATION TISSUE, SCARRING IS MORE PREVALENT
EX: BURNS DEEP LACERATIONS, EDGES ARE NOT APPROXIMATED |
|
TERTIARY INTENTION
|
THERE IS A DELAY B/T THE INJURY AND WOUND CLOSURE OR DELAYED PRIMARY CLOSURE, WOUND IS PURPOSELY LEFT OPEN, DEEPER WIDER SCAR IS COMMON
EX: BAD TRAUMA OR INFECTIONS FROM SURGERY GANGRENOUS |
|
PUSTULE
|
ELEVATED LESION CONTAINING PURULENT MATERIAL (ACNE)
|
|
VESICLE
|
ELEVATED SHARPLY DEFINED LESION CONTAINING SEROUS MATERIAL (BLISTER)
|
|
SEROUS
|
CLEAR AND WATERY DRAINAGE
|
|
SAGUIENEOUS
|
RED AND WATERY DRAINAGE
|
|
PURULENT
|
PUS THICK YELLOW, TAN , GREEN OR BROWN
|
|
DEHISCENCE
|
TOTAL OR PARTIAL DISRUPTION IN WOUND EDGES (WOUND SEPARATION)
|
|
EVISCERATION
|
PROTRUSION OF VISCERA THROUGH AN ABDOMINAL WOUND FISTULA
|
|
COMMUNICATION
|
NURSE MUST APPRECIATE HER OWN BACKGROUND AND AT THE SAME TIME ACKNOWLEDGE THE DIFFERENT PERSPECTIVE HELD BY THE CLIENT
|
|
METHODS OF COMMUNICATION
|
VERBAL AND NONVERBAL
|
|
VERBAL COMMUNICATION
|
SPEAKING/ LISTENING AND WRITING/ READING
|
|
NONVERBAL COMMUNICATION
|
BODY LANGUAGE, GESTURES, FACIAL EXPRESSIONS, POSTURE AND GAIT, TONE OF VOICE, EYE CONTACT, TOUCH, BODY POSITION
|
|
SIMPLICITY
|
USE OF WORDS COMMONLY UNDERSTOOD
|
|
BREVITY
|
ASPECT OF SIMPLICITY USING SHORT SENTENCES AND AVOIDING UNNECESSARY MATERIAL
|
|
CLARITY
|
SAYING EXACTLY WHAT IS MEANT
|
|
TIMING OF COMMUNICATION
|
MUST BE APPROPRIATE TO ENSURE WORDS ARE HEARD
|
|
RELEVANCE OF COMMUNICATION
|
MAKING SURE THE MESSAGES RELATE TO THE CLIENT
|
|
INTONATION OF THE VOICE
|
CAN EXPRESS HOW THE PERSON IS FEELING
|
|
ASPECTS OF THERAPEUTIC COMMUNICATION
|
OBTAIN OR PROVIDE INFO.
DEV ELOPE TRUST SHOW CARING EXPLORE FEELINGS |
|
TECHNIQUES OF THERAPEUTIC COMMUNICATION
|
1. ATTENDING OR OFFERING SELF, IS MAKING ONESELF AVAILABLE TO LISTEN TO THE CLIENT
2. FOCUSING IS KEEPING THE COMMUNICATION FOCUSED ON THE TOPIC 3. CLARIFYING AND VALIDATION ARE USED WHEN THE NURSE IS NOT SURE OF THE MEANING OF A MESSAGE 4. REFLECTING IS REPEATING ALL OR PART OF A MESSAGE BACK TO THE SENDER 5. PARAPHRASING IS RESTATING THE MESSAGE IN THE RECEIVERS OWN WORDS 6. OPEN QUESTIONS ENCOURAGE THE CLIENT TO EXPRESS HIS OR HER OWN THOUGHTS AND FEELINGS 7. SUMMARIZING OR HIGHLIGHTING 8. SILENCE CAN BE A VALUABLE THERAPEUTIC TECHNIQUE |
|
BARRIERS TO COMMUNICATION
|
CLOSED QUESTIONS, STEREOTYPING, FALSE REASSURANCE, GIVING ADVICE, CLICHES, JUDGMENTAL OR MORALISTIC RESPONSES, DEFENDING, A REQUEST FOR A EXPLANATION OF BEHAVIORS CAN BE INTIMIDATING, CHANGING SUBJECT ABRUPTLY
|
|
NURSE/CLIENT RELATIONSHIP
INTRODUCTORY OR ORIENTATION PHASE |
NURSE INTRODUCES SELF AND SETS TONE FOR REST OF RELATIONSHIP
|
|
NURSE/ CLIENT RELATIONSHIP
WORKING PHASE |
USED TO ACCOMPLISH GOAL OR OBJECTIVE DEFINED DURING INTRO. PERIOD
|
|
NURSE/ CLIENT RELATIONSHIP
TERMINATION PHASE |
FINAL PHASE WHICH ENDS THE RELATIONSHIP
|
|
CHARACTERISTICS OF NURSE/ CLIENT RELATIONSHIP
|
RESPECT, GENUINENESS, EMPATHY
|
|
THERAPEUTIC COMMUNICATION KEY INGREDIENTS
|
EMPATHY, POSITIVE REGARD, COMFORTABLE SENSE OF SELF
|
|
SCHEDULE I CONTROLLED SUBSTANCE
|
HIGH ABUSE POTENTIAL
HEROIN, LSD, MARIJUANA |
|
SCHEDULE II CONTROLLED SUBSTANCE
|
MEDICAL USE WITH HIGH POTENTIAL FOR ABUSE
AMPHETAMINES, CODEINE, MEMPRIDINE, METHADONE |
|
SCHEDULE III CONTROLLED SUBSTANCE
|
MEDICAL USE WITH ABUSE POTENTIAL LESS THAN II'S
PROPOSYPHEN, SOME CODEINE |
|
SCHEDULE IV CONTROLLED SUBSTANCE
|
MEDICAL USE WITH LIMITED RISK OF ABUSE
(BEZODIAZEPINES, NON NARCOTICS, PHENOBARBITAL) |
|
SCHEDULE V CONTROLLED SUBSTANCE
|
MEDICAL USE WITH MINIMAL RISK OF ABUSE
OPIOID DIARRHEALS AND COUGH SYRUPS |
|
NURSING GUIDELINES FOR CONTROLLED SUBSTANCES
|
1. DOUBLE LOCKED 2. ONGOING RECORD KEPT 3. WASTES COSIGNED 4. COUNTED AT BEGIN AND END OF EACH SHIFT 5. DISCREPANCIES ARE REPORTED 6. SIGNED OUT WITH NAME, DATE, TIME OF ADMINISTRATION
|
|
1G = 1,000mg =
|
1,000,000 mcg
|
|
DOSE ON HAND /QUANTITY ONHAND =DESIRED DOSE/QUANITY DESIRED
|
AMOUNT TO ADMINISTER
|
|
IV FLOW RATE FORMULA
|
VOLUME TO BE INFUSED/TOTAL TIME IN MIN X DROP FACTOR = RATE OF FLOW
|
|
DRUG ACTIONS
|
MECHANISM, THERAPEUTIC SIDE EFFECT, TOXIC EFFECT, ALLERGIC RESPONSE, IDIOSYNCRATIC RESPONSE,
|
|
ALLERGIC RESPONSE
|
SUPPORTIVE CARE AND ADMINISTRATION OF EPI, BRONCHODIALATORS, ANTIHISTAMINES, CORTICOSTEROIDS
|
|
IDIOSYNCRATIC RESPONSE
|
UNEXPLAINED UNPREDICTABLE RESPONSE TO A MED
|
|
5 RIGHTS TO MED ADMINISTRATION
|
DRUG
DOSE CLIENT ROUTE TIME |