FUNDAMENTALS OF NURSING

MIDTERM REVIEWER

Critical pathway

Also known as care and clinical pathway. It is one of the main tools used to manage the quality in healthcare concerning the standardization of care proceses.

Critical pathway

it has been shown that their implementation reduces the variability in clinical practice and improves outcomes.

Clinical pathway

aims to promote organized and efficient patient care based on evidence - based medicine .

Case management

is a collaborative process of assessment, planning, facilitation, care ,coordination, and advocacy for services to meet an individual's comprehensive health needs through communication available resources to promote quality of care.

Handoff report

a process of exchanging vital patient information, responsibility and accountability between the off-going and coming nurses to ensure safe continuity of care and delivery of best clinical practices.

Nursing Diagnosis

is a clinical judgement concerning human response to health conditions, life process or vulnerability.

priority setting

ordering of nursing diagnosis or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions.

Nursing Intervention

is any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes.

planning

the nurse collaborates with the patient, family and health care providers team to determine the urgency of identifying problems.

planning

a deliberative, systematic phase of nursing process that involves decision making and problem- solving.

initial planning
ongoing planning
discharge planning

3 Types of Planning

initial planning

admission assessment, beginning of the comprehensive plan of care for the patient

ongoing planning

done by all nurses who work with the client , occurs at the beginning of the shift as the nurse plans the care to be given that day.

ongoing planning

is to determine whether the client's health status has changed and to set priorities for the clients care during the shift.

ongoing planning

to decide which problem to focus on.

discharge planning

the process of anticipating and planning the needs of patient after discharge

priority setting

ordering of nursing diagnosis which they may use models such as Maslow's Hierarchy of Human Needs or the ABC's.

high

if untreated, result in harm to patient and others

low

may not always related to a specific illness but affect the patient's future well being.

intermediate

non emergent, non life treatening

goal

is the ultimate outcome

outcomes

a measurable changes that must be achieved to reach a goal

Patient
centerd goal

it is focused on patient's specific behavior not the nurse goal.

Nursing

sensitive patient outcome is a measurable patient, family, state, behavior, or perception largely influenced by and sensitive to nursing interventions. Reduction in pain and severity

subject

a noun, client, any part of the client

verb

specifies an action the client is to perform

Conditions/ modifiers

added to the verb to explain the what, why, when, where, how

Criterion

a level which a patient will perform specified behavior,(time, speed, accuracy, distance)

specific

address only one behavior perception or physiological response

Nursing Intervention

this includes direct and indirect care measures aimed at individuals, families, and community.

timed

provide time frame ( short and long term goal)

measurable

quantify the expected change in physiologic findings, patient's knowledge, perceptions, and behavior.

attainable

consider the patient desire to recover .

realistic

set goals and outcomes within patient's limitations and abilities.

NCP

this include nursing diagnosis, goals and a section for evaluation findings, so any nurse is able to quickly identify a patient's clinical need and situation.

Nursing care plan

this formally begins after the development of the plan of care

Dependent

actions that require an order from the health care provider such as administering medication and implementing an invasive procedure

Independent

actions that a nurse can perform without supervision or direction from others

Interdependent( collaborative)

are the therapies that require the combine knowledge, skill and expertise of multiple health care providers.

Implementation

each interaction with the client on this phase is an opportunity to assess and reassess the ongoing data and compare it to baseline.

Diagnosis

involves critical thought and judgement to analyze, organize, an interpret assessment data.

Assessment

includes collection, validation and organization of data.

Nursing Process

is a cyclic , ongoing method of providing client centered care

NCP

a document that provide s direction on the type of nursing care the individual, family may need.

NCP

this may be subject to revision when the patient's status changes implementation.

H or S

dose on hand or stock

D

desired dose/ dose ordered by the doctor

TID

3 times a day

BID

2 times a day

Evaluation

like assessment, it is an ongoing and cyclical activity. This will also help the nurses to decide whether to modify or to end the plan of care.

Evaluation

measures the effectiveness of nursing care and quality of care provided.

Signa

direction for the patient

Subscription

is the instruction to the pharmacist

Inscription

includes name of the drug, and type of preparation

V or Q

form which the drug comes such as liquid or tablet, capsule.

Superscription

the Rx symbol on the form. It also means recipe

Children ways of administering medications

dosing spoons, table spoons, oral syringes

Infants ways of administering medications

medicine droppers, dosing syringe

Adults ways of administering medications

dosing cup, calibrated medicine glass or plastic cups.

Unscored

cannot be divided

Scored tablet

can be divided

Transcription

means copying information from the pharmacy

Latex free stopper

prevents leakage of medication and act as an indicator for measuring the syringe's contents.

Graduations

scale markings typically in cubic centimeter cc or milliliter ml units

Barrel

reservoir for holding liquid, clearly graduated to allow accurate and visual measurement of the syringe's contents

Flanges

the "wings" that just out from the side of the syringe barrel that provide an area or surface for the index finger and middle finger to grasp during administration.

Plunger rod

a piston- like device inside the barrel

Thumb press

area where person presses to push plunger rod down into barrel to expel contents.

The needle

is used to penetrate the tissues. It is composed of the shaft and lumen

Shaft

is the length of the needle and is measured in terms of inches

Lumen

is the hole inside the shaft and it is measure in terms of gauge .

Intradermal

needle gauge :25-26

Subcutaneous

needle gauge: 23-27

Intramuscular

needle gauge: 16-23

Intradermal Injection

the drug is administered into the dermis. Most of the time this method is used to performed sensitivity tests or a skin test to determine if the patient is allergic to the drug.

The barrel

it carries the fluid . It measures the amount of fluid inside in terms of cc or ml.

The hub or hilt

is where the needle is connected and rests.

Needle Adapter

is the opening of the hub. It connects the needle to the barel.

Subcutaneous Injection

the drug is administered under the skin or tissue. Commonly used in insulin administration of diabetic patient.

Intramuscular Injection

the drug is administered into a muscle tissues.

Intramuscular site of Injection

deltoid, vastus lateralis, dorsogluteal muscles

Subcutaneous site of Injection

upper arm, buttocks, abdomen, thigh

Intradermal site of Injection

Inner aspect of the fore arm away from blood vessels.

Source Oriented Record

traditional client record and each of person or department makes notations in a separate section or sections of the client's chart

Problem- Oriented Medical Record

established by Lawrence Weed in 1960's, the data are arranged according to the problems the client has rather than the source of information.

PIE

information are into three categories. This consists of a client care assessment flow sheet and progress notes.

Focus Charting

is intended to make the client concerns and strengths the focus of care.

Charting by Exception

a documentation system in which only abnormal or significant findings or exception to norms are recorded.

Case Management

emphasizes quality, cost effective care delivered within an established length of stay.

Assessment Documentation Form

initial assessment form, various flow sheets

Diagnosis Documentation Form

ncp, critical pathway, progress notes, problem list

Planning Documentation Form

ncp, critical pathway

Implementing Documentation Form

progress notes, flow sheets

Evaluating Documentation Form

progress notes

Client Records

are legal documents that provide evidence of a client's care

Source Oriented Clinical Records

each health care professional group provide its own record

Computer Terminals

allows immediate documentation of nursing actions.

The Kardex

is used to organize client data, making information quick, access for health professionals

Care Plan Conference

a meeting of a group of nurses to discuss possible solutions to certain problems of a client.

Long term Documentation

this varies depending on the level of care provided and requirements set by Medicare and Medicaid.