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Trial and error problem solvin
Not effective, not acceptable, Can be dangerous
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Intuitive thinking problem solving
"Going with your gut",
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Scientific Problem Solving
systematic, uses scientific method, has steps, used in a controlled setting
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Methodical Reasoning problem solving
Step by Step reasoning
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Why do you need a database?
Establish baseline and use this to measure from. Identify strengths.
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What are the benefits of the nursing process?
Individualized care= efficiency, Systematic, dynamic, collaborative= continuity of care.
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Define Critical Thinking
A systematic way to form and shape thinking. Based on intellectual standards, comprehensive, disciplined.
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How do you develop technical skills?
Practice until you feel/are competent and confident. Know new equipment, ask for help.
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Describe the Nursing Process
Systematic, collects data through assessment, Patient centered- identifies goals, strengths & actual/potential problems. Outcome based- intervention to reach with help of patient.
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Define assessment
- Collect
- Validate
- Communicate
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Types of nursing assessments
- Initial: establish complete database for problem identification and planning.
- Focused: Collect data on a specific problem.
- Emergency: Identify life threatening problems.
- Time-lapse: Compare current status to baseline.
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What is subjective data?
The patient's report, not measurable
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What is objective data?
Assessment, data collection that is measurable
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What is the primary source for information to patient history
The patient (family secondary)
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Why is validation important?
Keep free from error, bias, and misinterpretation.
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What is the diagnosis used for?
Implementing nursing interventions related to symptoms
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What is the difference between a medical and a nursing diagnosis?
- Medical: Identifies the disease.
- Nursing: Focussed on unhealthy responses to health and illness.
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What are the types of nursing diagnosis?
- Actual: Major defining factors.
- Risk: make a clinical judgment the patient is vulnerable for.
- Possible: Suspected problem that needs more data.
- Wellness: Transition from one level of wellness to a higher level of wellness
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What is the purpose of outcomes (Goals)
Establish priorities, identify outcome with patient, communicate plan of care with patient
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When is discharge planning identified?
Concurrently, always
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What is implementation?
Initiate interventions
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What is nurse-initiated interventions?
Autonomous, clinical judgement, focused on patient outcomes.
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What is physician-initiated interventions
Dependent nursing action to carry out a doctor's order. Nurses are still accountable
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What are collaborative interventions?
inter-dependent nursing
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What is evaluation?
Measuring accomplishment of outcome (goal), reassess if not met.
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Purpose of patient record
Specific detailed information about patient that facilitates patient care. A financial/legal tool. Communication tool.
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What is focus charting?
Focus on the patients concerns. DARE charting (used in ER)
- Data
- Assessment
- Response
- Evaluate
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What is the legal recourse for not documenting?
If it's not charted, it didn't happen.
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What is Safety and Security (Maslow's 2nd level)
Freedom from danger, harm, risk. A concern that underlines all nursing care.
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Techniques for fall prevention...
Hand rails, proper lighting, clutter free environment, dispose broken equipment, low bed position, lock breaks on wheelchair & beds
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What are two types of restraints
- Chemical
- Physical/mechanical
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When are side rails x 4 not considered a restraint?
Patient requests it (need to sign a consent form), seizure precautions
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Medication and Joint Commission Safety to prevent errors
- Patient Identification x 2 identifiers
- 3 checks
- 7 rights
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What is the benefit to assist with patient bath?
Assess skin integrity, develop rapport
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Phases of healing
- Hemostasis
- Inflammatory Process
- Proliferation
- Maturation Phase
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Hemostasis
Start of blood clotting, 1st phase of wound healing
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Inflammatory Process
Swelling. 2nd phase of wound healing
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Proliferation
New tissue starts to form from the inside 3rd phase of wound healing
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Maturation Phase
Scar tissue formation. Last phase of wound healing
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Factors in Pressure Ulcer Development
- External pressure: Between a surface and the bone
- Friction: Wrinkled sheets
- Sheering: When patient is pulled instead of lifted up bed
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Pressure Ulcer Staging
- Stage 1: red, does not blanch.
- Stage 2: Shallow crater, partial thickness loss
- Stage 3: Partial to full thickness, possible tunneling, cannot see bone, tendon
- Stage 4: Full thickness, can see muscle, bone & tendon
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What are prevention measures for Pressure Ulcers
- Reposition patient at least every 2 hours
- Assess skin each shift
- Float heels
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How long should heat/cold application be left on?
20 min every 1 hour
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Purpose of heat therapy
- Dilate vessels
- reduce muscle tension
- relieve pain
- Attract oxygen & nutrients to the site
- Increase leukocytes for inflammatory response.
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Purpose of cold therapy
- Constricts blood vessels
- Reduce edema & inflammation
- Reduce muscle spasms
- Control bleeding
- Reduce pain
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Nurse role to promote body mechanics
Assess/support patient to make lifestyle changes. Focus on regular exercise to slow aging process.
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Effects of immobility on the body
- Cardiac: Increased cardiac workload.
- Pulmonary: Decreased ventilation, increased secretions.
- Muscle/skeletal: Weakness, atrophy, contractures.
- GI: Constipation, poor digestion
- GU: Stasis (slow flow), UTI, Stones
- Skin: Breakdown
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What is assessed in a patient that has compromised mobility?
- Muscle mass
- Tone
- Strength
- Endurance
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Patient teaching in regards to immobility.
Regular exercise to reduce adverse effects on the body.
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