NURSING 100 MIDTERM
"How to Make an Accurate Nursing Diagnosis" - ANS-"Know the various N.A.N.D.A. Diagnoses
Collect VALID and PERTINENT data
Cluster relevant data
Differentiate Nursing from collaborative problems (Medicine's issues)
Formulate the Diagnosis CORRECTLY
Focus on the PRIORITY diagnosis!"
"standard of care" - ANS-(creates a legal expectation that you will meet!) is that ALL nursing
care plans with be reviewed every 72 hours in an acute care facility!
(HAI) - ANS-infections result from delivery of health services in a health care facility.
(INFLAM 1) ARTERIOLAR DILATATION (STAYS AT) - ANS-Causes redness and increased
warmth
(INFLAM 2)VASCULAR AND CELLULAR RESPONSE - - ANS--Changes in capilary permability
allows necessary fluids, cells to enter the interstitial space for repair .
-Causes swelling (stretch causes pain)= edema, red, hot, tender, swollen
-White cell phagocytize bacteria = exudate (fluid result of leaking protein from white cell)
e.g.:pus
6 important factors to choosing interventions - ANS-1) characteristics of the nursing diagnosis,
(2) goals and expected outcomes, (3) evidence base for the interventions, (4) feasibility of the
intervention, (5) acceptability to the patient, (6) your own competency.
A nursing intervention - ANS-any treatment based on clinical judgment and knowledge that a
nurse performs to enhance patient outcomes.
Acuity records - ANS--useful for determining hours of care and staff required for a given group
of patients. A
- justify overtime and the number and qualifications of staff needed to safely care for patients.
ACUTUAL NURSING DIAGNOSIS - ANS-human response to health conditions or life processes
that exist in an individual, family, or community.
ADPIE (NURSING PROCESS) - ANS-Assessment
Diagnosis
Identifies Outcomes
Planning
Implementation
Evaluation
adverse reaction - ANS-harmful or unintended effect of a medication, diagnostic test, or
therapeutic intervention.
Nurses try to reduce or counteract reaction>
Airborne precautions - droplet nuclei less than 5 microns - ANS-Chickenpox, pulmonary or
laryngeal TB
PPE REQUIRED:
, - Private room, negative-pressure airflow (air is sucked out)
-six exchanges/hr
-N95 Mask or respiratory protection device
Assessment (ADPIE) - ANS-systematically collect, validate, organize and communicate the
client data -moves from general to specific.
-nurse obtains relevant, accurate, and complete information for the assessment database.
*risk that standard assessment does not capture a patient's full story.
Back channeling - ANS-Active listening prompts such as "all right," "go on," and "uh-huh."
-These indicate you have heard what the patient says and are interested in hearing the full story.
BACTERIAL GROWTH - ANS-Temperature - ideal temp. for human pathogens is 95deg and
cold temps.
*Extremes tend to prevent growth & reproduction of bacteria (Bacteriostasis)
*Temp. that destroys bacteria is bactericidal
pH -acidity of environment determines viability of organism - pH range of 5 to 8
Light - MO thrive in dark environments:
-under dressings, within body cavities.
*who put it on, how long has it been on, must constantly replace and keep fresh
CARE DELIVERY STEPS ALONE - ANS-Introduce self
Lean forward, nod, smile = attendant behaviors
CHECK BAND AND HAVE PATIENT STATE NAME/DOB
State purpose
Complete procedure
DOCUMENT!!
CARE DELIVERY STEPS W OTHERS - ANS-Verify doctor's order
Gather Equipment
Identify areas where assistance is needed
Assemble personnel
Chain of Infection: Infection occurs in a cycle - ANS-infectious agent
reservoir (source for pathogen growth)
port of exit from the reservoir
mode of transmission
port entry to a host
susceptible host
Charting by exception - ANS-focuses on documenting deviations from established norms.
CLINICAL APPEARANCE OF INFECTION (LAB) - ANS--WBCs (5000-10,000/mm3)
-Inc Sed. Rate (how fast it becomes sediment)?
"How to Make an Accurate Nursing Diagnosis" - ANS-"Know the various N.A.N.D.A. Diagnoses
Collect VALID and PERTINENT data
Cluster relevant data
Differentiate Nursing from collaborative problems (Medicine's issues)
Formulate the Diagnosis CORRECTLY
Focus on the PRIORITY diagnosis!"
"standard of care" - ANS-(creates a legal expectation that you will meet!) is that ALL nursing
care plans with be reviewed every 72 hours in an acute care facility!
(HAI) - ANS-infections result from delivery of health services in a health care facility.
(INFLAM 1) ARTERIOLAR DILATATION (STAYS AT) - ANS-Causes redness and increased
warmth
(INFLAM 2)VASCULAR AND CELLULAR RESPONSE - - ANS--Changes in capilary permability
allows necessary fluids, cells to enter the interstitial space for repair .
-Causes swelling (stretch causes pain)= edema, red, hot, tender, swollen
-White cell phagocytize bacteria = exudate (fluid result of leaking protein from white cell)
e.g.:pus
6 important factors to choosing interventions - ANS-1) characteristics of the nursing diagnosis,
(2) goals and expected outcomes, (3) evidence base for the interventions, (4) feasibility of the
intervention, (5) acceptability to the patient, (6) your own competency.
A nursing intervention - ANS-any treatment based on clinical judgment and knowledge that a
nurse performs to enhance patient outcomes.
Acuity records - ANS--useful for determining hours of care and staff required for a given group
of patients. A
- justify overtime and the number and qualifications of staff needed to safely care for patients.
ACUTUAL NURSING DIAGNOSIS - ANS-human response to health conditions or life processes
that exist in an individual, family, or community.
ADPIE (NURSING PROCESS) - ANS-Assessment
Diagnosis
Identifies Outcomes
Planning
Implementation
Evaluation
adverse reaction - ANS-harmful or unintended effect of a medication, diagnostic test, or
therapeutic intervention.
Nurses try to reduce or counteract reaction>
Airborne precautions - droplet nuclei less than 5 microns - ANS-Chickenpox, pulmonary or
laryngeal TB
PPE REQUIRED:
, - Private room, negative-pressure airflow (air is sucked out)
-six exchanges/hr
-N95 Mask or respiratory protection device
Assessment (ADPIE) - ANS-systematically collect, validate, organize and communicate the
client data -moves from general to specific.
-nurse obtains relevant, accurate, and complete information for the assessment database.
*risk that standard assessment does not capture a patient's full story.
Back channeling - ANS-Active listening prompts such as "all right," "go on," and "uh-huh."
-These indicate you have heard what the patient says and are interested in hearing the full story.
BACTERIAL GROWTH - ANS-Temperature - ideal temp. for human pathogens is 95deg and
cold temps.
*Extremes tend to prevent growth & reproduction of bacteria (Bacteriostasis)
*Temp. that destroys bacteria is bactericidal
pH -acidity of environment determines viability of organism - pH range of 5 to 8
Light - MO thrive in dark environments:
-under dressings, within body cavities.
*who put it on, how long has it been on, must constantly replace and keep fresh
CARE DELIVERY STEPS ALONE - ANS-Introduce self
Lean forward, nod, smile = attendant behaviors
CHECK BAND AND HAVE PATIENT STATE NAME/DOB
State purpose
Complete procedure
DOCUMENT!!
CARE DELIVERY STEPS W OTHERS - ANS-Verify doctor's order
Gather Equipment
Identify areas where assistance is needed
Assemble personnel
Chain of Infection: Infection occurs in a cycle - ANS-infectious agent
reservoir (source for pathogen growth)
port of exit from the reservoir
mode of transmission
port entry to a host
susceptible host
Charting by exception - ANS-focuses on documenting deviations from established norms.
CLINICAL APPEARANCE OF INFECTION (LAB) - ANS--WBCs (5000-10,000/mm3)
-Inc Sed. Rate (how fast it becomes sediment)?
