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