Nursing

Nursing 175 with Sandy at Grant MacEwan Community College

About this deck

By: Michelle Andringa
Textbook:

Canadian Fundamentals of Nursing
Created: 2011-04-19
Size: 128 flashcards
Views: 820

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Determinants of Health

Income and Social Status
Social Support Networks
Culture
Gender
Biological and Genetic Endowment
Social Environment
Physical Environment
Education and Literacy
Working environment
Healthy Child development
Health Services
Individual health practices and coping skills

Health Promotion

directed toward increasing the level of well being and self- actualization

Disease Prevention

action to avoid illness/ disease

Three levels of intervention

1. Primary: before signs and symptoms occur
2. Secondary: early detections
3. Tertiary: disease is present

Health Promotion Strategies

Build Healthy Public Policy
Create supportive environments
Strengthen Community Action
Develop Personal Skills
Reorient Health Services

Spirituality

based on a person's culture, life experieces beliefs and values about life

Spiritual well being

state of wholeness or health when people find a balance between their life values goals and belief systems including their relationships with themselves and others

Grief

the emotional response to loss or death

Bereavement

grief and mourning stat of having lost a significant other to death

Theories of Grief

Kubler- Ross Stages of Dying
Bowlby's Phases of Mourning
Wordens Four Tasks of Mourning

Kubler Ross Grief Process

- Shock and denial
- Anger:
- Bargaining
- Depression
- Acceptance

This is a continual process and may not be linear

Mind Mapping

- visual technique for showing graphic relationshiops among ideas and concepts

Nursing Process

Assessment
Diagnosis
Planning
Intervention
Evaluation

Health History

systematically collecting analyzing and communicating data about the clients level of wellness

Primary: Patient
Secondary sources: family, HC workers ect.

Phases of Therapeutic Interview

Interaction: review the chart, setting goals, assess the environment
orientation: meets client- gather health status info
working: nurse + client work to solve problems
Termination: summarize important points. ask the client if summary was accurate

Aphasia

Difficulty understanding speech or expressing oneself verbally

Receptive: difficulty understanding spoken language
difficulty understanding text

Expressive: Difficulty speaking

Unresponsive

Never assume the patient Can't hear you!
- orient to person place and time
- preferred name

PQRST

P - provokes
Q- quality
R- radiates
S- severity
T- time

Interdisciplinary approach to care

Continuing of care is comprehensive, coordinated and integrated provision of health services

Subjective

immeasurable
perspective of the person
thoughts
beliefs
feelings ect

Objective

measurable, something other than the client

SOLER

Sit squarely
Open posture
Listen Actively
Eye contact
Relax

McGill Model defines health as...

personal coping and development

Choose appropriate goals and plan effective interventions

Piaget'd Theory of Cognitive Development
Ericson's Theory of Psychosocial Development

Chronic Illness

Impairment in function or a disease state that is irreversible

Acute Illness

immediate health problem that can be diagnosed and treated over a short period of time (less than 3 months)

Long Term Care

24 hour care for residents of any age with chronic or debilitating illness

Palliative Treatment

care delivered to relieve or reduce intensity of discomfort, but not to produce a cure

Definitive Treatment

thearpy generally expected to produce a cure

Holistic approach

physical, emotional, social, economic and spiritual needs of the client

The experience of being ill...

Time
Space
Morality
Aesthetics
Technology
Information
Interpersonal Relationships

Potential Issues

Altered self-esteem
Altered Body Image
Powerlessness
Loss
Hopelessness
Guilt
Anxiety/ Fear
Defense mechanisms
Coping mechanisms
Resilience

Piaget- Cognitive

Period 1: Sensorimotor (birth - 2 yrs)
Period 2: Preoperational (2- 7 yrs)
Period 3: Concrete Operations (7 - 11 yrs)
Period 4: Formal Operations (11 - adulthood)

Piaget- Moral

Premoral
Conversational
autonomous

Kohlberg's Theory of Moral Development

Pre-conventional Level (based on personal gain)
Conventional Level (moral reasoning based on personal internalization of others expectations
Post-conventional Level (balance between human rights and societal rules)

Ericson

Trust vs Mistrust (infancy)
Autonomy vs Sense of Shame and doubt (toddler)
Initiative vs Guilt (preschool)
Industry vs Inferiority (middle childhood)
Identity vs Role Confusion (adolescence)
Intimacy vs Isolation (young adult)
Generativity vs Self-Absorption and Stagnation (middle hood)
Integrity vs despair (old age)

Types of Development

Biophysical
Cognitive
Moral
Psycosocial

Delerium

acute confusional state

Dementia

loss of memory, judgement, and reasoning

Depression

reduces happiness and well-being, contributes to physical and social limitations

Adverse events

unintended injuries or complications caused by health care management rather than by the patients underlying disease that lead to death or disability at the time of discharge or prolonged hospital stays

Common Adverse Events

Falls- highest rate of incidence
Client related accidents- client is primary reason
Procedure related- during therapy - med errors ect
Equipment Related - malfunction of misuse of equipment

Ways to avoid injury

WHIMIS
Body mechanics
Fire procedures
Standard Precautions/ Infection Control
Follow policies and procedures

Factors that contribute to unsafe environment

Personal characteristics of client
Environmental facotrs
Staffing

Contribute to safety

- research
- system restructuring
- education initiatives
- new legislation/ policies
- new practices

Nurse contribute to safety

- Avoid short cuts
- Know your scope of practice
- Follow best practice guidelines
- Follow agency policies

Policies and procedures should be based on...

best practice

Best practice is.....informed

evidence informed

Asepsis

absence of pathogenic microorganisms

Medical Asepsis

clean technique (routine procedure) breaks chain of infection

Control the mode of transmission by...

washing hands

Control the portal of entry by

PPE

Chain of infection:

Reservoir
Portal of entry/exit
Modes of transmission:
- Direct: person to person
- Indirect: contaminated material
Portal of entry into host

Hand Hygiene

- before and after direct contact with patients
- before and after donning of gloves
- after contact with bodily excretions
- handling of food
- bagging waste or linen

Tier 1

Standard Precautions: hand washing ect

Teir 2

Isolation
Airborne: airborne droplets (door close, N95 mask
Droplet: droplets produced by coughing, sneezing or talking (mask)
Contact: direct/indirect contact with patient or contents (gloves, gown,- equipment to be kept in room)
Significant organism:

Health promotion

Passive: implemented thorugh public health
Active: changes in lifestyle

Client record

confidential
permanent
legal documentation
interdisciplinary

How is the date written

Day/ Month (in letters)/ Year (4 digits)

20/April/2011

Time is...

military time

3:00 pm is

1500

Never erase or white out errors

single line
initial
date and correction

As a macwan nursing student

NS MacEwan

Types of documentation

- narrative documentation
- Problem- Oriented Medical Records (POMR)
- Source Records
- Charting by exception
- Case management plan or Care maps

SOAP/ SOAPIE and PIE (Organize narrative progress notes)

S- Subjective
O- Objective
A- Assessment
P- Plan

I- Intervention
E- Evaluation

P- Problem
I- Intervention
E- Evaluation

Comfort:

- outcomes, ease, well-being and satisfaction

- relief

Kolcaba

Relief, ease, transcendence

Physical, psychospiritual, sociocultural and environmental

1) Physical: hygiene needs
2) Psycho-spiritual: spiritual care
3) social cultural: family traditions/ rituals
4) environmental: room too hot/ cold

Relief

the state of having a specific comfort need met

Ease

The state of calm or contentment

Transcendence

The state in which one can rise about problems or pain

Decreased Skin tugor =

possible dehydration

Eye Care

wash from inner to outer

Pressure ulcers: document

- location
- size
- color
- open
- draining

and what did you do about it!? Intervention

Braden Scale

validated tool for assessing pressure ulcers

- sensory perception
- moisture
- activity
- nutrition
- friction and shear

Impede healing

- infection
- malnutrition
- age
-obesity
- impaired )2
- Lack of positioning
- smoking
- wet linen

Management of pressure ulcers

Manage Moisture
Mange nutrition
Manage friction and shear
position every 2 hours

Stage 1 of pressure ulcer

ulcer is superficial, abrasion, blister, skin tear, or shallow center

Stage 2

Skin breakdown
reddened

Stage 3

Full thickness skin loss

Stage 4

Full thickness skin loss, extensive tissue damage to muscle, bone or supporting structures

Dysphagia

Difficulty swallowing

Contribute to ulcers:

Intensity
Duration
Tissue Tolerance

Spirituality

based on a person's culture, life experiences, beliefs and values about life

Spiritual well being: state of wholeness or health

McGill Model

Inability of the family/ community resources to support client health

Diagnosis

Process: used to interpret nursing assessment
and product

Steps in assessmentq

- interpret the data
- Verifying the diagnosis (problem)
- Labeling and recording the diagnosis

Diagnosis

- Nursing
- Medical Diagnosis
- Collaborative Problems

Nursing Diagnosis

Clinical judgement about a client's responses to actual, potential (risk) or possible health problems

NANDA

Actual nursing diagnoses
Risk nursing diagnoses
Health- promotion nursing diagnoses
Wellness nursing diagnoses

Include...

Problem + etiology (cause)

Swelling related to fractured femur
(problem) (cause)

Risk Management Defined

Process involving the identification, selection and evaluation of measure to reduce hazards to human health

Risk Management

Estimate Risk
Evaluate Risk
Identify Options
Make Decisions
Act

Clients Eating

75 - 90 Degrees

Planning phase of nursing

collaborate between nurses, family and client for desired outcomes from the diagnosis and identifies nursing interventions to achieve those goals

determine the patient's strengths

Goals of care

specific, measurable and behavioural responses

Planning

Setting priorities among diagnosis
Establishing goals and outcomes
Select appropriate nursing interventions
Developing or revising a plan of care

Guidelines for written goals and outcomes

Clieint/ patient centered
Singular
Observable
Measurable
Time limited
Mutually set
Realistic

SMART

S- singular
M- measurable
A- achievable
T- timely

Planning using

NOC

Nursing Outcome classification

NIC

Nursing Intervention classification

Outcome statement

guide the planning of care and the evaluation of changes in patient health status

Interventions

Independent: those nurses are licensed to prescribe, perfome or delgate basd on their knowledge and skills

Dependent: prescribed by physician and carried out by nurse

Interdependent: carried out in collaboration with other health care professionals

TED stocking

Thromboembolic device

aid in maintaining external pressure on the muscles of the lower extremities and thus promote venous return

Nursing implementation provides....

actual interventions and client responses that are then reviewed in the Evaluation Phase

- the data is used to identify new diagnoses or to revise existing diagnoses

Question........orders

question - medical- orders

Evaluation

judgement is made about the quality, value or worth of something by comparing it to previously identified criteria or standards

Justice principle

in the sense of fairness- good planning is critical to the fairness of the patient

Delegation

transfer of responsibility for the performance of a task or activity from one person to another while retaining accountability for the outcome

Criteria

measurable or observable qualities that describe specific skills, knowledge, behaviors ect.

Teaching

interactive process that promotes learning
- formal teaching -planned and goal directed (class room setting)

- informal teaching- initiated at any time a learning need is identified

About this deck

By: Michelle Andringa
Textbook:

Canadian Fundamentals of Nursing
Created: 2011-04-19
Size: 128 flashcards
Views: 820

About StudyBlue

“I have been getting MUCH better grades on all my tests for school. Flash cards, notes, and quizzes are great on here. Thanks!”
Kathy