Funds Exam 3

nursing process

assess, diagnose, plan, implement, evaluate

assess

gather info about patient’s condition

diagnose

identify patient’s problems

plan

set goals of care/ desired outcomes + identify appropriate nursing actions

implement

perform nursing actions identified in planning

evaluate

determine if goals/ expected outcomes are achieved

primary source of data

patient

secondary source of data

family/ significant others, health care team, medical records, scientific literature, nurse’s experience

nursing health history

biographical info, patient expectations, reason for seeking care, present illness/ health concerns, health history, family history, environmental history, psychosocial history, spiritual health, ROS, documentation of findings

subjective data

patient’s verbal description

objective data

observations by another person

components of nursing diagnosis

problem, etiology, signs/ symptoms

problem

end result of the process of using assessment data to create a nursing diagnosis

etiology

clinical criteria/ assessment findings

signs/ symptoms

objective/ subjective data

medical diagnosis

identification of a disease condition based on specific evaluation of signs/ symptoms

nursing diagnosis

actual/ potential complication that nurses monitor to detect a change in patient status

problem-focused nursing diagnosis

describes specific clinical judgement concerning an undesirable human response to a health condition/ life process that exists

risk nursing diagnosis

describes human responses to health conditions/ life process that may develop

health promotion

clinical judgement concerning a patient’s motivation/ desire to increase well-being/ actualize human health potential

etiology (criteria)

suspected cause; “related to”; driect at behaviors/ conditions nurse can see; NO MEDICAL DIAGNOSES

signs/ symptoms (criteria)

“as evidence by” (insert subjective/ objective data)

risk problems (criteria)

no evidence statement; can use medical diagnosis

patient goals/ expected outcomes

patient centered; written in general terms: predicted resolution of diagnosis, progress toward improved health status, maitenance of good health

SMART goals

specific, measurable, attainable, realistic, timed

role of nurse in setting patient goals/ expected outcomes

partner; mutual goal setting; prioritizing goals of care/ developing plan of action

nursing intervention factors

desired patient outcomes, characteristics of nursing diagnosis, research base knowledge, feasibility, acceptability, nurse’s own competency

evaluation/ outcome

should directly refer to nursing diagnosis/ goal

reassessing a patient

assessment is continuous; focuses on one primary nursing diagnosis/ one dimension of a patient; helps nurses decide if proposed nursing actions are still appropiate

standards of patient education

Joint Commission sets standard; collaboration b/t health care professionals; all state Nurse Practice Acts recognize that it falls w/i scope of nursing

purpose of patient education

to help achieve optimum levels of health

patient education components

maitenance/ promotion of health/ illness prevention; restoration of health; coping w/ impaired function

teaching

interactive process that promotes learning

learning

purposeful acquisition of knowledge, skills, behaviors, attitudes

role of nurse in teaching/ learning

identify when patients are ready to learn, determine what patient, teach information

when does discharge planning start?

upon admission

basic learning principles

motivation to learn, ability to learn, learning environment

health literacy

cognitive/ social skills that determine the motivation/ ability to gain access to, understand, and use information that promote/ maintain health

domains of learning

cognitive, affective, psychomotor

cognitive

all intellectual behaviors/ requires thinking

affective

expression of feelings/ acceptance of attitudes, opinion, values

psychomotor

acquiring skills that require integration of mental/ muscular activity

digestive system (beginning/ end)

mouth/ anus

components of small intestine

duodenum, jejunum, ileum

components of colon

ascending, transverse, descending, sigmoid

what happens in the colon?

water reabsorption

bowel assessment

usual elimination pattern, description of stool, changes in appetite, diet hx, intake, hx of surgery, medication hx

what is used for people w/ spinal cord injuries for bowel movements?

bowel training

what does the biscodyl/ “magic bullet” do

stimulate peristalsis

what does absent bowel sounds indicate

paralytic ileus/ small bowel obstruction

bowel physical assessment

inspect mouth/ abdomen, auscultate bowel sounds, percuss, palpate

factors that influence bowel elimination

age, diet, fluid intake, physical activity, psychological factors, pregnancy, surgery/anesthesia, medications

common bowel elimination problems

constipation, impaction, diarrhea, fecal incontinence, flatulence, hemorrhoids

ways to mitigate constipation

high fiber diet, increase fluid intake, ambulation

sign of impaction

leak of watery seepage

what helps with hemorrhoids?

witch hazel pads

function of enemas

cleansing

tap water enema

stimulates evacuation; never repeated due to potential water toxicity

normal saline enema

safest due to equal osmotic pressure; volume stimulates peristalsis

hypertonic enema

low volume; good for patients that can’t tolerate high volume enemas

fleet enema

commercially prepared hypertonic enema

soapsuds enema

pure castile soap in tap water/ normal saline; acts as an irritant to promote peristalsis

oil retention

lubricates rectum/ colon for easier passage of stool

Kayexalate enema

high K⁺ levels

enema equipment

gloves, lubricant, absorbent waterproof pads, bedpan/bedside commode/ toilet, IV pole, enema bag w/ tubing/ prepackaged enema

bowel diversion

reroutes normal flow of stool

stoma

temporary/ permanent artificial opening in abdominal wall

normal stoma appearance

pink/ moist

distance b/t stoma/ appliance

1/8”

stoma at ileum

ileostomy

stoma at colon

colostomy

type of stool from ileostomy

liquid

potential complications from ileostomy

fluid-electrolyte imbalance, skin breakdown (rich in digestive enzymes)

type of stool from sigmoid colostomy

fully formed

care of ostomies

assessing stoma, change bag, maintenance of skin integrity, nutritional considerations, fluid intake, psychological considerations

how long ostomy bag lasts

5 days

how often should you empty ostomy bag

every shift

muco-cutaneous junction

area of stoma sutured to abdominal wall

normal peristomal skin

flat/ intact

significant increased size/ length of stoma

prolapsed

laboratory test

fecal occult blood testing

fecal occult blood test protocol

gather necessary equipment —> explain procedure —> client may collect own specimen but use collection device —> hand hygiene —> apply gloves —> use wooden applicator to obtain small sample —> follow directions

reason for fecal occult blood testing

GI bleed; can be from aspirin/NSAIDs

could give a false positive for fecal occult blood testing

iron supplement, heavy meal; red meat

direct visualization of GI tract

endoscopy, colonoscopy

indirect visualization of GI tract

x-ray film w/ contrast, US of abdomen, CT of abdomen, MRI

kidneys

remove waste from blood to form urine

ureters

transport urine from kidneys to bladder

bladder

reservoir for urine until urge to urinate develops

urethra

urine travels from bladder/ exits through urethral meatus

glomerulus/ nephrons

filtration, resorption, secretion, excretion

ADH/ vasopressin

increases water/ sodium retention, vasoconstriction, increase in BP

where ADH/ vasopressin is synthesized/ stored

hypothalamus/ pituitary gland

RAAS system

renin —> angiotensinogen —> angiotensin I —> (ACE) angiotensin II —> vasoconstriction/ aldosterone release/ sodium+water retention —> increase BV/ BP

physical assessment

skin/ mucosal membranes (assess hydration), kidneys (flank pain), bladder (distended bladder), urethra (discharge, inflammation, lesions)

intake/ output

minimum of 30 mL/hour

normal color of urine

pale straw to amber

normal clarity for urine

clear

cloudy urine

UTI

normal odor of urine

ammonia in nature