Nurse Role of Lecture (Misty)
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- An actual nursing diagnosis contains 3 parts: what are they?
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1. Problem (NANDA format)
2. Etiology ("related to")
3. Defining characteristics (AEB) -
True or False:
If a nursing diagnosis contans "at risk for," then there will be no signs or symptoms, or "AEB." - True
- An "at risk for" diagnosis contains 2 parts: what are they?
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1. Problem (NANDA format)
2. Etiology ("related to") - A wellness diagnosis has only one part: what is it?
- Problem (NANDA format)
- The "planning" phase of the nursing process requires the nurse to perform four important functions: what are they?
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1. Set priorities, in order of importance
2. Establish client goals
3. Select nursing interventions
4. Determine resources - In setting priorities, the nurse's #1 priority is what?
- Keep the patient alive! (Breathing, Circulation and Safety)
- "A specific aim planned by the nurse AND the client to assist the client in achieving maximal level of wellness" is the definition of what?
- Goal Setting
- When setting goals, we should remember the acronym S.M.A.R.T. What do these letters stand for?
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S = specific
M = measurable
A = attainable
R = realistic
T = timed - When setting goals, the nurse should avoid which words in order to ensure that the goals are specific and measurable?
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adequate
fewer/more
understand(s)
increase/decrease
improve
frequent
appropriate
"Pt. will be free of..." - Goals should begin with what statement?
- "The client will..."
- Goals should answer what 3 questions?
-
Who?
What?
When? - Goals should always match what?
- the Nursing Diagnosis
- What are the 4 factors involved in selecting the appropriate nursing interventions?
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1. Defining characteristics of the nursing dx.
2. Research associated with interventions
3. Client's acceptance of disease, health cond., handicap, etc.
4. Least amount of risk/discomfort for the client - According the the Nurse Practice Act, the RN will do what regarding pt. education?
- "Promote and participate in client education, based on health needs."
- What should a nurse include in educating a client who will be undergoing chemotherapy?
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hair loss
decrease in energy
side effects
survival chances (if appropriate) - What should a nurse include in educating new parents who are about to take their baby home?
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car seat safety
breast feeding - What should a nurse include in educating a newly diagnosed diabetes patient?
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1. explain the disease process of diabetes
2. explain signs/symptoms of complications
3. explain what to do if glucose gets too high/low
4. how to use glucometer
5. diet - The term "survival skills" usually refers to whom?
- Newly diagnosed diabetics
- This semester, our role as student nurses will include what five principles?
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1. Demonstrating effective communication
2. Providing things for the pt.
3. Competency in clinical skills
4. Critical thinking in assessment
5. Applying the nursing process to clinical situations - The key principle of Nursing I was "formulating the nursing diagnosis." What is the key principle of Nursing II?
- Implementation
- What types of tasks can be delegated to unlicensed hospital personnel (CNA, etc.)?
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* ADL's
* Baths
* Bed changes
* Data collection
* Recording pain scale - What are the "4 C's" of Delegation?
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1. Clear
2. Concise
3. Correct
4. Complete - What are the "4 rights" of Delegation?
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1. Right task
2. Right person
3. Right communication
4. Right feedback/follow-up - What does "Accountability" refer to in the role of the nurse?
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1. Knowing the rules / regulations of being an RN
2. How supplies are used - The nurse should always chart as if he/she were charting for whom?
- A jury
- On a Flow Sheet, the "Time" column is used to record what?
- The actual time of the assessment
- How often should a nurse make entries in the Narrative Notes?
- At least every 2 hours
- Documentation such as "visiting with family," or "watching TV," are examples of what?
- Fillers - those things that a nurse charts when he/she can't think of anything else to chart
- Instead of using "fillers," what would a nurse chart INSTEAD of "client is sleeping quietly?"
- "Checked on client at xx:xx (time), to assess IV site."
- When performing a neuro check, what should be assessed and documented?
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* Level of Consciousness
* Alert & Oriented x 3
* Mental status
* PERLA
* Motor function
* Sensory function - When auscultating in a cardio assessment, what should the nurse listen for?
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* Extra (split) sounds
* Murmurs
* Rate
* Regular/irregular rhythm - Besides auscultating, what other things are included in a cardio assessment?
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* Telemetry #
* Rhythm
* Pulse
* Capillary refill
* Periphery (is skin wet/dry)
* Pt. status
* Pacemaker settings (capture/non-capture) - What should be DOCUMENTED in a cardio assessment?
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* Rate
* Rhythm
* Telemetry
* Auscultation
* Abnormalities in skin periphery
* Cyanosis
* Pt. status
* Pacemaker settings (capture/non-capture)