Intervent 1

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  1. critical thinking
    • a reflective thinking process that involves collecting information, analyzing the adequacy and accuracy of the information, and carefully considering options for action
    • Used in every aspect of nursing
  2. Nursing process
    a systematic problem-solving process that guides all nursing actions
  3. What are the steps to the nursing process
    • Assessment
    • Nursing Dx
    • Planning
    • --planning outcomes
    • --planning interventions
    • Implementation
    • Evaluation
  4. Nursing diagnosis
    • based on a pt's response to treatment of problem or disease
    • Focuses on pt
  5. medical dx
    • describes a disease, illness or injury
    • purpose is to ID a pathology so appropriate med treatment can be given
    • more narrowly focused than nursing dx
  6. nursing intervention
    actions, based on clinical judgement and nursing knowledge, that nurses perform to achieve client outcomes
  7. Therapeutic communication
    Comprised of 5 communication qualities:

    • empathy
    • respect
    • genuineness
    • concreteness
    • confrontation
  8. empathy
    the desire to understand and be sensitive to the feelings, beliefs, and situation of another person
  9. respect
    communicated by valuing the client and being flexible to meet the client's needs
  10. genuineness
    the ability to respond honestly
  11. Concreteness & confrontation
    • concreteness refers to answering questions in specific terms of what you mean
    • message must be constructed and delivered in manner suitable fo client
    • If client is unable to express thoughts clearly, you must be able to confront him/her to request clarification
    • you must also be wiling to be confronted if you are unclear
  12. Types of charting
    • Narrative
    • PIE
    • SOAPIE
    • Focus
    • FACT system
  13. Narrative type of charting
    • tells story in chronological way
    • basically time line
    • Always end w safety
    • Benefits: especially useful when attempting to construct a timeline of events, such as cardiac arrest or emergency situation. 
    • highlights critical thinking and captures true art of nursing
  14. PIE
    • Problem
    • Intervention
    • Evaluation
    • *Tents to focus only on the listed problems and not client as a whole
  15. SOAPIE
    • Subjective
    • Objective
    • Assessment
    • Plan
    • Interventions
    • Evaluate
    • *organized to specific pt problems
  16. Focus charting
    • uses assessment data to evaluate client care concerns, problems or strengths
    • ID's necessary revisions to care plan
    • Generally has 3 columns, one for each letter in DAR
    • Data, Action, Response
    • *attractive cause it addresses the client's concerns holistically
  17. FACT
    • Flowsheet
    • Assessment
    • Concise
    • Time

    • charting by exception
    • preprinted, charing "normal" by marking a check, if "abnormal" then documented
    • *includes only exceptions to the norm. eliminated need to chart normal findings
  18. Charting by exception
    • more than a format
    • a system of charting in which only significant findings or exceptions to standards and norms of care are charted
  19. Source-oriented records
    • for collaborative pts
    • members of each discipline record findings on separately labeled section
    • Benefit is you can easily find care provided by each discipline and results to labs and diagnostic tests
  20. Electronic health record systems
    combines source-oriented and POR's
  21. POR's
    • Problem-oriented reports in collaborative pts 
    • organized around pt problems
    • no separate sections for each discipline
    • makes it easy for all disciplines to monitor pt progress in shared notes
  22. advance directive
    group of instructions stating a person's wishes regarding his healthcare if he were incapacitated or unable to make decisions
  23. living will
    • type of advance directive:
    • a document that provides specific instructions about the kinds of healthcare the person would wish or would wish not ro have in particular situations
  24. DPOA
    • durable power of attorney or healthcare proxy
    • type of advance directive
    • exists when another person is ID's to make decisions for an individual regarding healthcare choices when he is unable to do so based on circumstances (irreversible coma, terminal illness
  25. collaborative problem
    • potential complication
    • cant be prevented with nursing interventions alone
    • brings many different professions together to solve problem
  26. outcomes in nursing process
    the client outcomes you want to achieve through your nursing interventions
  27. HAI
    • healthcare-associated infection
    • refers to infections associated w healthcare given in any setting
    • will affect 1 out of 20 pts
  28. nosocomial infections
    refers more specifically to hospital-aquired infections
  29. ways to classify infections
    • local or systemic
    • primary or secondary
    • exogenous or endogenous
    • acute or chronic
  30. Local vs systemic infections
    Local infections: infections that cause harm in limited region of body (ex: in upper respiratory tract, the urethra, single bone or joint)

    Systemic infections: occur when pathogens invade to blood or lymph and spread throughout the body
  31. bacteremia
    the clinical presence of bacteria in the blood
  32. septicemia
    symptomatic system infection spread via the blood
  33. Primary vs secondary infections
    • Primary infection is first infection that occurs in pt
    • Secondary infections follow primary infection. Common for immunocompromised pts. (Ex: frail client w pneumonia may develop herpes zoster ~ aka. shingles ~ related to stress of illness
  34. exogenous  healthcare-related infection
    the pathogen is acquired from the healthcare environment
  35. endogenous healthcare-related infection
    pathogen arises form pt's normal flora, when some form of treatment (ex: chemo or antibiotics) causes normally harmless microbe to multiply and infect
  36. Latent infections
    • cause no symptoms for long periods of time, even decades
    • Ex: TB, HIV
  37. stages of infection
    • Incubation
    • prodromal stage
    • illness
    • decline
    • convalescence
  38. incubation
    stage of infection btwn successful invasion of pathogen into body and first appearance of symptoms
  39. prodromal stage
    • 2nd stage of infection
    • characterized by first appearance of vague symptoms
    • Ex: person infected w cold virus may experience a mild throat irritation
    • *not all infections have this stage
  40. Illness
    • 3rd stage of infection
    • marked by appearance of S/S characteristic of disease
    • If pt immune defences and med treatments are ineffective, this stage ends in death
  41. Decline
    • 4th stage of infection
    • stage pt immune defenses, along w med therapies, successfully reduce # of pathogenic microbes
    • S/S begin to fade
  42. Convalescence
    • 5th stage of infection
    • characterized by tissue repair and a return to health as remaining # of microbes approaches zero
    • could take 1 day, or require a yr or more
  43. fomite
    • type of mode of transmission
    • indirect contact
    • a contaminated object that tranfers a pathogen
  44. Chain of infection
    • Infectious agent ~ bacteria/pathogen
    • resides in 
    • Reservoir ~ source of infection. Ex: human body, food, water, surfaces, etc.
    • until it finds 
    • Portal of Exit ~ path infectious agent leaves reservoir  ex: body fluid, cough, direct contact
    • and it's 
    • Mode of Transmission ~ how it travels to susceptible host ex: either direct/indirect = droplet, fomite, vector 
    • once landed, searches for 
    • Portal of Entry ~ can be normal or abnormal body opening
    • it now makes new home in 
    • Susceptible Host
  45. defenses against disease
    • primary
    • secondary
    • tertiary
  46. Primary defense against disease
    • Non-specific
    • Always first line of defense
    • bacteria have to get past this to compromise
    • *Ex: intact skin, GI tract, mouth
  47. Secondary defense against disease
    • non-specific
    • involves phagocytosis, complement cascade, inflammation, fever
  48. phagocytosis
    • the process by which phagocytes (specialized WBC) engulf and destroy pathogens
    • Phagocytic WBC's include neutrophils, monocytes and eosinophils
  49. complement cascade
    • a process by which a set of blood proteins, called complement, triggers the release of chemicals that attach the cell membranes of pathogens, causing them to rupture
    • Also signals basophils (WBC's) to release histamine, which prompts inflammation
  50. Tertiary
    • specific immunity
    • body creates antibodies against specific pathogens
  51. active immunity
    occurs when body makes it's own antibodies or T cells to protect the body against a pathogen
  52. asepsis
    means absence of contamination by disease causing microorganisms
  53. medical asepsis
    • absence from contamination
    • done by:
    • regular hand-washing
    • alcohol base sanitizer
    • keeping environment clean
  54. surgical asepsis
    • creation of sterile environment
    • more complex
    • not needed for every pt
    • Ex: NICU, operating room, bedside procedures
  55. drug resistant pathogens
    • MRSA
    • VRE
    • C-Diff
  56. MRSA
    • Methicillin-resistant staphylococcus aureus
    • lives on skin & in nose w/o causing probs
    • If person does get "staph" infection, can't be killed by methicillian
    • Can be fatal
    • spread by skin to skin contact 
    • living in crowded places risky
  57. VRE
    • Vancomycin-resistant enterococci
    • normal residents in intestines and female genital tract
    • most infections occur in hospital
    • leading cause of healthcare-acquired bacteremia, surgical infections and UTI
  58. C-Diff
    • get it from lack of good bacteria in intestine
    • spores can't be killed w alcohol based hand sanatizer
    • only way to prevent contact transmission is hand washing w soap & water
    • found in stool
    • major symptom is diarrhea
  59. CDC guidelines for preventing transmission of pathogens
    • Tier 1 = standard precautions, apply to care of all pts
    • Tier 2 = Transmission-based precautions
    • Tier 3 = Isolation
  60. Explain Tier 1 of CDC's guidelines for preventing transmission of pathogens
    • Standard precautions
    • Use w all clients in all settings
    • remember all body fluids, blood, ect may contain pathogens
    • Include hand hygiene; use of gloves, gown, mask, eye protection or face shield (depending on expected exposure) and safe injection practices
    • Practice respiratory hygiene and cough etiquette
  61. Explain Tier 2 of CDC's guidelines for preventing transmission of pathogens
    • Use for pts known or suspected to be infected w infectious agents
    • Used in addition to standard precautions
    • 3 categories: Contact, Droplet, Airborne precautions
  62. contact precautions
    • wear non sterile gloves
    • wear clean gown 
    • Remove PPE and observe hand hygiene before leaving room
    • use disposable equipment
  63. diseases needing contact precautions
    • MRSA
    • Scabies ~ Mite
    • Herpes-Zoster (shingles) 
    • Diarrhea
  64. droplet precautions
    • keep droplet precautions outside pt room
    • wear mask, donning on entry
    • change PPE and preform hand hygiene btwn pts
  65. Diseases to use droplet precautions
    • Flu
    • Viral resp tract inf = RSV, rhinovirus (add contact)
    • Pneumonia, scarlet fever
    • Pertussis
    • Strep
    • Rubella
    • Mumps
  66. airborne precautions
    • keep airborne supplies outside pt room
    • Don mask on entry, wear special fitted N-95 respirator if pt has TB or smallpox
    • remove respirator/mask outside room after closing door
  67. Diseases to use airborn
    • Measles
    • TB
    • Chicken pox
    • Shingles (Herpes zoster)
    • Cough in pt w risk of tb
  68. Explain Tier 3 of CDC's guidelines for preventing transmission of pathogens
    • used for clients w low WBC counts, those undergoing chemotherapy, or clients w large open wounds or weak immune systmes
    • Includes following standard precautions, placing pt in private room, restricting visitors, wearing mask, etc.
  69. protective isolation
    • same thing as reverse isolation
    • used on clients with low WBC counts, clients undergoing chemo, or clients w large open wounds or weak immune systems
    • Follows standard precautions
    • pt in private room
    • restricting visitors
    • wearing mask, gown, and gloves
  70. Jaundice
    • yellow discoloration of the skin which can be caused by accumulation of bile pigments and is symptom of certain diseases
    • causes skin to be itchy and dry
  71. Pallor
    • a light-skinned person may appear as pale skin w/o underlying pink tones
    • in dark-skinned person, observe for ashen gray or yellow color
  72. erythema
    • redness of skin
    • related to vasodilation and inflammation
  73. cyanosis
    • a bluish coloring of skin, caused by decreased peripheral circulation or decreased oxygenation of blood
    • may be related to cardiac, pulmonary, or peripheral vascular problems
  74. Rules of delegating hygiene care
    Can delegate to licenced and/or non licensed as long as it's within their scope of practise

    • Delegate with clear & concise instructions
    • provide specific time frame
    • Follow up to ensure proper completion
  75. Functions of the skin
    • Protection - first line of defense
    • Sensation
    • Regulation -temp
    • Secretion/excretion - secretes waste products
    • Vitamin D formation - from ultraviolet light of sun
  76. Factors affecting skin
    • Dampness
    • Dehydration
    • Nutritional status
    • Insufficient circulation
    • Skin diseases
    • jaundice
    • Lifestyle and personal choices
  77. Explain effects of dampness on skin
    • Excessive perspiration and incontinence cause skin to be damp
    • Skin breaks down more easily when damp, especially in skinfolds
  78. maceration
    • softening of skin from prolonged moisture
    • makes epidermis more susceptible to injury
    • especially in skin folds
  79. excoriation
    • loss of superficial layers of skin
    • ex: scratching and by digestive enzymes in feces
  80. dehydration effects on the skin
    • Fluid loss and insufficient fluid intake can lead to dehydration
    • this causes the skin to become dry and crack easily
  81. Nutritional status affecting skin
    • people who are very thin or very obese are more likely to experience skin irritation and injury
    • Morbid obesity makes it difficult to reach all body areas, leading to development of odor and fungal conditions
  82. Insufficient circulation affecting skin
    • immobility, vascular disease, and overall inadequate nutritional status may compromise skin
    • predisposes pt to local tissue death and ulceration when skin cells do not receive enuf oxygen
  83. Skin diseases affecting skin health
    diseases such as impetigo (bacterial infection) and systemic diseases (like measles and chickenpox) cause lesions that create discomfort and require special hygiene care
  84. Lifestyle and personal choices affecting skin health
    • some people damage skin by exposure to uv rays because they want to tan
    • skin tattoos or piercings create risk for systemic and local infection and scarring
  85. Rest vs. sleep
    • Rest is a condition in which the body is inactive or engaging mild activity, after which person feels refreshed
    • Sleep is a cyclically occurring state of decreased motor activity and perception
  86. Interventions to promote sleep
    • Schedule nursing care to avoid interrupting sleep
    • create a restful environment
    • promote comfort
    • support bedtime rituals and routines
    • Offer appropriate bedtime snacks or beverages
    • Promote relaxation (guided imagery, music therapy, progressive muscle relaxation)
    • Teach sleep hygiene
    • Maintain pt safety
    • medication
  87. parasomnias
    • sleepwalking
    • sleeptalking
    • bruxism
    • night terrors
    • REM sleep behavior disorders
    • Nocturnal Enuresis
  88. somnambulism
    • sleepwalking
    • occurs during stage 3 sleep, usually 2 hrs after person falls asleep
  89. bruxism
    grinding and clinching of the teeth
  90. sleep apnea
    • periodic interruption in breathing during sleep
    • an absence of air flow through the nose or mouth during sleep
  91. enuresis
    nocturnal enuresis = bedwetting
  92. sleeptalking
    • occurs during NREM sleep
    • usually doesn't interfere w rest but may disturb partner
  93. night terrors
    sudden arousals in which person (often child) is physically active, often hallucinatory, and expresses a strong emotion such as terror
  94. REM sleep behavior disorders
    • are associated w REM (or dreaming period)
    • the sleeper violently acts out the dream
    • People have injured themselves and others waking
Card Set
Intervent 1
nursing interventions exam `1
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