Skills Chapter 4 5 30 & 31

  1. Critical Thinking
    Using skillful reasoning and logical thought to determine the merits of a belief or action
  2. Steps of the nursing process
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • Evaluation
  3. Nursing diagnoses
    Related to the needs or problems the patient is experiencing
  4. Maslow's Hierarchy of Needs
    • Physiological
    • Safety and Security
    • Love and Belonging
    • Self-Esteem
    • Cognitive
    • Aesthetic
    • Self actualization
    • Transcendence
  5. Documentation
    The act of charting or making written notation of all the things that are pertinent to each patient for whom you provide care, also considered to be one of the most important tasks you will perform on a daily basis
  6. Purposes of Documentation
    • To communicate pertinent data that all health care team members need in order to provide continuity of care
    • To provide a permanent record of medial diagnoses, nursing diagnoses, the plan of care, the care provided, and the patient's response to care
    • To serve as a record of accountability of quality assurance, accreditation, and reimbursement purposes
    • To serve as a legal record for both the patient and the health care provider
  7. The Joint Commisssion
    Sets the standards by which the quality of health care is measured both nationally and internationally
  8. Why would you write an incident report?
    • Medication error
    • patient injury
    • employee injury
    • safety hazard
    • failure of an appropriate response to an emergency
    • failure to perform ordered care
    • loss of patient's belongings
    • refusal of treatment
  9. Guidelines for Documentation
    • Use blue or black ink
    • write neatly and legibly
    • sign each entry
    • include the date and time with each entry - military time
    • follow chronological order
    • make entries in a timely manner
    • be succinct
    • use punctuation properly
    • use only approved abbreviations
    • be accurate
    • do not leave blank lines
    • use continued notes
    • correct mistaken entries - line through, initials, and error
    • keep the medical record intact
  10. SOAPIER Charting
    • Subjective Data
    • Objective Data
    • Assessment Data
    • Plan
    • Intervention
    • Evaluation
    • Revision
  11. DAR Charting
    • Data
    • Action
    • Response
  12. Narrative Charting
    Charting in the form of a story, uses paragraphs, and written in chronological order
  13. Charting by Exception
    Charting only abnormal findings
  14. Defaction
    The process of bowel elimination
  15. Peristalsis
    the rhythmic wave-like movements that begin in the esophagus and continue to the rectum
  16. Normal Flora
    Bacteria that is present to prevent infection and maintain health
  17. Flatus
    The gas that is produced when normal flora interact with the chyme
  18. Nurses Elimination Goal
    The goal of your elimination care is to maintain the patient's normal frequency pattern of bowel elimination, or as close to it as possible
  19. Normal Characteristics of Stool
    • Light Yellowish-Brown
    • Curved Shape
    • Red or Green - Variations due to dietary intake
    • Black - Iron
  20. Abnormal Characteristics of Stool
    • Smaller balls or clumps
    • Liquid or semiliquid
    • Watery stools
  21. Constipation
    Term used for less frequent, hard, formed stools that are difficult to expel. May include bloating
  22. Impaction
    The blockage of the movement of contents through the intestines by a bulk mass of very hard stool
  23. Diarrhea
    Loose or watery stools occurring three or more times a day
  24. Where does fecal impaction occur?
    May occur in the rectum, the sigmoid flexure, or any part of the large colon
  25. Who is greater at risk for fecal impaction?
    • Elders
    • Patients on bedrest
    • Those who are severely dehydrated
  26. What can happen if fecal impaction is not relieved?
    Obstruction or perforation of the bowel wall
  27. How do you ensure that an elderly patient receives adequate fluid intake?
    • pt will only take a few sips at a time
    • make sure to provide a drink every 15 to 20 minutes
  28. Void
    to urinate
  29. Hematuria
    Invisible or hidden blood that is present in urine
  30. Polyuria
    Output greater than 3,000 mL/day
  31. Anuria
    Absence of urine
  32. Normal pH of urine
    4.6 to 8.0
  33. Urinary Retention
    The inability to empty the bladder at all or the inability to completely empty the bladder
  34. Residual Urine
    Urine that remains in the bladder after the patient voids
  35. Nocturia
    When a person wakes during the night to urinate
  36. What can you tell a pt to do to manage incontinence?
    Kegel exercises
  37. Indwelling Catheter
    • Foley catheter
    • Remains in bladder for extended period of time
  38. Straight Catheter
    • Used only to obtain a specimen
    • Used as a one time use to empty the bladder
  39. Coude Catheter
    • Used for pts with prostrate problems
    • Curved on the end for easier insertion
  40. Three Way Catheter
    • Empties Urines
    • Provides Area for Flush
    • Ability to inflate balloon 

    • Continuous bladder irrigation
    • Used for TURP patients
  41. Condom Catheter
    • Non-invasive
    • For male use only
  42. How will the facility receive payment for nonsocomial infections such as a UTI when related to catheter insertion?
    Facility will not receive payment because it is an HAI
  43. Continent Urostomy
    • Pouch is created from the intestine
    • Ureters empty into the pouch
  44. Pyelonephritis
    • Kidney Infection
    • can lead to renal scarring and eventually the loss of kidney function
  45. Patients with a UTI are encouraged to drink what?
    Cranberry Juice
  46. Before inserting an indwelling catheter you should..?
    Clean pt perineal area with warm water and soap
  47. Which of the following may decrease the incidence of urinary tract infection?
    Using a diaphragm
    Increasing fluid intake
    Voiding after intercourse
    Frequent voiding
    Increasing fluid intake, voiding after intercourse, and frequent voiding can all decrease the risk of a UTI
  48. Indicate the path of the flow of urine through the following structures by numbering them in order
    • Kidney
    • Ureter
    • Bladder
    • Urethra
    • Meatus
  49. Your patient has been diagnosed with an enlarged prostate. He is at risk for which of the following?
    Urinary suppression
    Urinary retention
    Urinary incontinence
    Urinary diversion
    Urinary Retention
  50. When reviewing the urinalysis results of a pt with the diagnosis of dehydration, which of the following would you expect to see?
    Specific gravity of 1.032
    pH of 7.0
    Specific gravity of 1.032
  51. Which of the following statements made by a pt with incontinence would indicate a need for further teaching?
    "I can stop doing Kegel exercises when i no longer have a problem with leaking"
    "I can take medication that may help with my incontinence"
    "I may need surgery if other treatments don't work"
    "I should start a moderate exercise program"
    "I can stop doing Kegel exercises when I no longer have a problem with leaking"
  52. You are initiating a 24 hour urine specimen collection for a pt as ordered by her health care provider. Which of the following would you do first?
    Post signs in the room stating there is a 24 hour urine specimen
    Place ice inside a 24 hour urine container
    Ask the pt to void, then discard the urine
    Ask the pt to void, then pour the urine into the 24 hour urine container
    Ask the pt to void, then discard the urine
  53. You have removed an indwelling catheter from a post surgical patient. Which of the following would be need to be reported to the health care provider?
    Eight hours after the catheter was removed, the pt has not voided
    Bladder scan reveals 50 mL of urine
    Voided urine is star-colored w/o sediment
    When assisted to the bedside commode, the pt complained of mild dizziness
    Eight hours after the catheter was removed, the pt has not voided
  54. Which of the following would be the most accurate statement about digestion and elimination?
    All individuals have at least one bowel movement daily
    An infant may have up to six bowel movements daily
    GI peristalsis increases with age, making incontinence a normal finding
    A stool is only considered normal if the color is a shade of brown
    An infant may have up to six bowel movements daily
  55. Indicate which of the following would be most likely to cause constipation in the pt:
    Magnesium citrate
    Ferrous sulfate
    Imodium AD
    Milk of magnesia
    • Amphogel
    • Meperidine
    • Ferrous sulfate
    • Imodium AD
  56. Kayexalate Enema
    Administered for the purpose of lowering a very high potassium level
  57. Harris Flush Enema / Return Flow Enema
    Used for the purpose of removing gas
  58. Which of the following S&S may indicate vagal stimulation during the digital removal of impaction?
    Complaint of rectal pressure
    Pulse rate of 42 BPM
    Complaint of difficulty breathing
    Moist skin
    Complant of abdominal cramping
    Complaint of feeling faint
    • Pulse rate of 42 BPM
    • Complaint of difficulty breathing
    • Moist skin
    • Complaint of feeling faint
  59. What of the following would be the best enema to administer to a pt before digital removal of an impaction?
    Siphon enema
    Oil retention enema
    Soapsuds enema
    Harris flush enema
    Oil retention enema
Card Set
Skills Chapter 4 5 30 & 31
Skills Chapter 4 5 30 & 31