PNR 104 Exam #2 Questions and Answers 100% Solved

PNR 104 Exam #2 Questions and Answers 100% Solved Steps of the nursing process in order Assessment, nursing dx, planning, implementation, and evaluation Assessment and nursing DX RN's are responsible for this part of the nursing process Data Collection LPN's main role in nursing process Documentation of the plan Should be constructed right after the admission database is collected. Must be readily available to each nurse who is assigned to the patient. (Reviewed & updated once every 24 hrs.) Problem solving process steps define the problem clearly, consider all possible alternatives as solutions to the problem, consider the possible outcomes for each alternative, predict the likelihood of each outcome occurring, choose the best alternative with the fewest undesirable outcomes. A medical diagnosis is never included in a nursing diagnosis True (example: stroke, MI) Nursing diagnosis = problem + etiology +signs and symptoms Etiology causes of the problem Defining characteristics characteristics that must be present for a nursing DX Constructing a nursing care plan assess the pt, analyze the data, identify nursing problems, prioritize, make goals, write expected outcomes, and choose interventions. purposes of charting written record of history, treatment, care, claims for reimbursement, and evidence in court 6 main methods of documentation source-oriented (narrative) charing, problem oriented medical record charting (POMR) focus charting, charting by exception, computer assisted charting, and case management system charting. source oriented charting (narrative) narrative notes are phrases and sentences written without any standardized structure. benefits of this method are that it gives info on pt condition in chronological order, indicates pt baseline for each shift, and includes aspects of all steps in the nursing process POMR focuses of patient status, emphasizing a problem solving approach. contains 5 steps - the data base, problem list, plan, progress note, and the discharge summary. This format is known as a SOAP(IE) note. s- subjective o - objective a- assessment p- plan i- implementation e- eval focus charting similar to POMR but it substitutes focus for the problem. 3 parts to this form of documentation are D - data A- action R- response (DAR) Advantage is that it keeps all relevant data to a problem in one place. Charting by exception decreases lengthy narrative entries to reduce repetition of data. computer assisted charting electronic health record (EHR) case management system charting method of organizing patient care through an episode of illness so that clinical outcomes are achieved in expected time and kept at a predictable cost. NOT good for court. Factors effecting communication emotions, culture, mood, past experience, attitude reflection reflects received message back to the pt, encourages further explanation from patient focusing asking a goal directed questions that helps the pt focus on key concerns ex - "do you have any questions about your chemotherapy?" Encouraging elaboration helps the pt describe more fully ex - "tell me what that felt like" silence allows patient time to gather thoughts and sort them out. therapeutic touch take into consideration their culture portuguese may find it reassuring, Koreans and japanese may find it offensive SBAR situation, background, assessment, recommendation effectively communication with a hearing impaired patient use short simple sentences, maintain a distance of about 2.5-4 ft, never shout, non verbal communication, short simple sentences 2 main reasons why proper body mechanics are important 1. the body functions best in anatomic position. 2. prevents injury Hazards of improper alignment ulcers, cramps, pulmonary edema, supine position pt resting on their back, recommended after spinal surgeries Fowler position elevating the head of the bed 60-90 degrees semi-fowler position 30-60 degrees low-fowler position 15-30 degrees Fowler's positions may help pt's who had a stroke and has paresis to swallow food and secretions Dorsal recumbent pt is on their back with their knees flexed and soles of their feet flat on the bed side lying or lateral position pt on their side and relieves pressure from bony prominences on their back Sims position a variation of the side lying position used for rectal exams prone position pt lying face down used for pts who have been on prolonged bed rest usually for pts with a spinal injury positioning devices pillows, boots, splints, footboards, side rails, trapeze bar, hand rolls, sandbags logrolling turning the pt as a single unit while maintaining straight body alignment at ALL times. often used for pts with injuries of surgery to the spine or those who must avoid twisting foot drop treatments most common is lightweight braces ROM (range of motion) pts who are paralyzed or have limited mobility need ROM exercises done to prevent joints from becoming rigid and immovable. repeat exercises 3-5 times per session. Factors affecting hygiene culture, ability to perform self care, and personal preference. pressure ulcers are most commonly seen on the elbow, heel, butt ox, shoulder, posterior knee stage 1 ulcer red or deep pink that does not blanch with fingertip pressure stage 2 ulcer partial thickness, skin loss. it may look like an abrasion, area surrounding skin may feel warm at this point stage 3 ulcer full thickness skin loss that looks like a deep crater. stage 4 ulcer full thickness skin loss with extensive damage to the bone or muscle. may appear dry and black with build up of tough tissue or wet and oozing unstageable ulcer loss of full thickness tissue, ulcer is covered by eschar (tan, brown, black) or the base of the ulcer contains slough (yellow, tan, gray, green) 4 basic components of bathing cleanse the skin, promote comfort, stimulate circulation, remove waste products secreted through the skin. mouth care for an unconscious patient atleast once every 8 hours (if the patient is mouth breathing do it every 4) minimizing noise in the health care setting avoid long conversations on the intercom by going to the patients room to talk, limit convos in the hallways and speak in lower toned voices. how to prevent falls assess the pt and label them as a fall risk if necessary, keep bed lowered, lock the wheels of the bed, answer calls quickly, toilet the pt on a regular schedule. how to protect from thermal injury use barriers between skin and thermal application, check temps of oral liquids and food before giving them to a patient, inspect electrical cords protective devices require a MD order in writing for a specific amount of time. (all 4 side rails are sometimes considered a as a restraint. maintaining pt safety while using protective devices should be applied snugly but should never be tight enough to impair neurovascular status pyrexia a fever is caused when the body can not keep up with the excessive heat production and body temp rises. altering the bodies internal enviroment and allowing it to become hotter before triggering natural cooling mechanisms permit the immune system to more effectively destroy bacteria and stimulate the immune system to produce more virus fighting substances physiologic mechanisms that control the pulse cardiac contractions how are respirations controlled the respiratory center works together with feedback mechanisms what physiologic factors direcetly affect the blood pressure the amount of cardiac outpit normal body temp 97.5-99.5 average pulse 60-100 abnormal characteristics of a pulse arrhythmia, poor force, fast, slow normal respirations 12-20 abnormal respiration patterns tachypnea, bradypnea, kussmaul (fast, deep) biot (equal deep respirations with periods of apnea), apnea, cheyne-stokes (faster, deeper, slower, shallow, with periods of apnea) factors influencing b/p age, stress, meds, enviroment, sex, exercise, body position, head injury korotkoff signs - signs you hear while taking a blood pressure phase 1 - tapping (inflating the cuff) auscultatory gap phase 2 - swishing (swishing sound while cuff starts to deflate) phase 3 - knocking ( louder knocking sounds with every heart beat) phase 4 - muffling (sudden change / muffling of sound which indicates systolic pressure) phase 5 - silence (diastolic) how does a nurse assess pain (the 5th vital sign) assessment must include location, intensity, character, frequency, and duration. the same version of that scale must be used each time at assessment. inspection using sense of sight observe the pt palpation touch percussion tapping auscultation listening to sounds in the body vesicular sounds soft, rustling sounds heard in the periphery of the lung fields bronchovesicular breath sounds heard over the central chest or back and are equal in length during inspiration and expiration wheeze musical and whistling rhonchi low pitched rattling sounds caused by secretions in the air passages crackles fine or coarse non musical sounds - they sound like rubbing two hairs between the fingers close to the ear stridor croaking or crowing sound needed for a basic assessment (RNS HOPE) R- rest and activity N- nutrition S- safety and security H- hygiene O- oxygenation P- psychosocial and learning E- elimination Glasgow Coma Scale used to score the neurological exam for pts with decreased levels of consciousness 1 t 5 ml 1 T 15 ml 1 oz 30 ml 1 pt 500 ml 1 qt 1000 ml 1 cup 8 oz 1 lb 16 oz 1 kg 2.2 lb 1 in 2.5 cm AC before meals PC after meals