Using skillful reasoning and logical thought to determine the merits of a belief or action
Steps of the nursing process
Assessment
Diagnosis
Planning
Implementation
Evaluation
Nursing diagnoses
Related to the needs or problems the patient is experiencing
Maslow's Hierarchy of Needs
Physiological
Safety and Security
Love and Belonging
Self-Esteem
Cognitive
Aesthetic
Self actualization
Transcendence
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
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
The Joint Commisssion
Sets the standards by which the quality of health care is measured both nationally and internationally
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
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
SOAPIER Charting
Subjective Data
Objective Data
Assessment Data
Plan
Intervention
Evaluation
Revision
DAR Charting
Data
Action
Response
Narrative Charting
Charting in the form of a story, uses paragraphs, and written in chronological order
Charting by Exception
Charting only abnormal findings
Defaction
The process of bowel elimination
Peristalsis
the rhythmic wave-like movements that begin in the esophagus and continue to the rectum
Normal Flora
Bacteria that is present to prevent infection and maintain health
Flatus
The gas that is produced when normal flora interact with the chyme
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
Normal Characteristics of Stool
Light Yellowish-Brown
Curved Shape
Red or Green - Variations due to dietary intake
Black - Iron
Abnormal Characteristics of Stool
Smaller balls or clumps
Liquid or semiliquid
Watery stools
Constipation
Term used for less frequent, hard, formed stools that are difficult to expel. May include bloating
Impaction
The blockage of the movement of contents through the intestines by a bulk mass of very hard stool
Diarrhea
Loose or watery stools occurring three or more times a day
Where does fecal impaction occur?
May occur in the rectum, the sigmoid flexure, or any part of the large colon
Who is greater at risk for fecal impaction?
Elders
Patients on bedrest
Those who are severely dehydrated
What can happen if fecal impaction is not relieved?
Obstruction or perforation of the bowel wall
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
Void
to urinate
Hematuria
Invisible or hidden blood that is present in urine
Polyuria
Output greater than 3,000 mL/day
Anuria
Absence of urine
Normal pH of urine
4.6 to 8.0
Urinary Retention
The inability to empty the bladder at all or the inability to completely empty the bladder
Residual Urine
Urine that remains in the bladder after the patient voids
Nocturia
When a person wakes during the night to urinate
What can you tell a pt to do to manage incontinence?
Kegel exercises
Indwelling Catheter
Foley catheter
Remains in bladder for extended period of time
Straight Catheter
Used only to obtain a specimen
Used as a one time use to empty the bladder
Coude Catheter
Used for pts with prostrate problems
Curved on the end for easier insertion
Three Way Catheter
Empties Urines
Provides Area for Flush
Ability to inflate balloonÂ
Continuous bladder irrigation
Used for TURP patients
Condom Catheter
Non-invasive
For male use only
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
Continent Urostomy
Pouch is created from the intestine
Ureters empty into the pouch
Pyelonephritis
Kidney Infection
can lead to renal scarring and eventually the loss of kidney function
Patients with a UTI are encouraged to drink what?
Cranberry Juice
Before inserting an indwelling catheter you should..?
Clean pt perineal area with warm water and soap
Which of the following may decrease the incidence of urinary tract infection?
C) Increasing fluid intake, voiding after intercourse, and frequent voiding can all decrease the risk of a UTI
Indicate the path of the flow of urine through the following structures by numbering them in order
E) Kidney
Ureter
Bladder
Urethra
Meatus
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
When reviewing the urinalysis results of a pt with the diagnosis of dehydration, which of the following would you expect to see?
A) Specific gravity of 1.032
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"
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?
B) Ask the pt to void, then discard the urine
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?
B) Eight hours after the catheter was removed, the pt has not voided
Which of the following would be the most accurate statement about digestion and elimination?
D) An infant may have up to six bowel movements daily
Indicate which of the following would be most likely to cause constipation in the pt:
D) Amphogel
Meperidine
Ferrous sulfate
Imodium AD
Kayexalate Enema
Administered for the purpose of lowering a very high potassium level
Harris Flush Enema / Return Flow Enema
Used for the purpose of removing gas
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
What of the following would be the best enema to administer to a pt before digital removal of an impaction?
