Nursing Process
The steps of nursing process
What are assessment, analysis, planning, implementation, and evaluation?
The steps of CJMM
What are recognize cues, analyze cues, prioritize hypotheses, generate hypotheses, take action, and evaluate outcomes?
The place that nursing diagnoses come from
What is NANDA?
Examples of ways we monitor fluid balance
What are intake & output, daily weight, blood pressure & heart rate, skin turgor, urine, edema, dry skin, mucus membranes, and subjective data?
The cause of UTIs
What is when viruses/fungi/bacteria (often E.coli) travels to places it should not be?
The purpose of the nursing process
What is the process is a systematic method that guides planning and provision of patient care?
The two main steps of analyzing data
What are cluster data and look for patterns?
The parts of a problem-focused nursing diagnosis
What are problem + etiology + defining characteristics?
The terms used to describe the two types of fluid imbalances and their definitions
What are
1) fluid volume deficit - aka dehydration; when more fluid is put out than taken in
2) fluid volume excess - aka fluid overload; when more fluid is taken in than the body can put out?
Upper vs. Lower UTIs
What is upper UTIs involve kidneys (aka pyelonephritis) and lower UTIs involve bladder & urethra (aka cystitis)?
The types of nursing interventions and descriptions
What are
-Direct vs. indirect = by the bedside vs. not by the bedside
-Independent vs. dependent vs. collaborative = by yourself vs. need provider order vs. need healthcare team?
Etiology vs. defining characteristics
What are etiology is the reason why patient has the problem and defining characteristics are the proof (aka the signs/symptoms)?
The formating of a health promotion/wellness nursing diagnosis
What is "readiness for enhanced" ...__ex. family processes__?
The nurse performs an assessment on an elderly client
who is suspected to be dehydrated. Which assessment
data would support this finding in an elderly client?
a. Heart rate of 62 bpm
b. Weight gain of 7 pounds (lbs.)
c. Urine output less than 20 milliliters in 1 hour
d. Blood pressure of 150/92
What is C. Urine output less than 20 milliliters in 1 hour?
Risk factors of UTIs
What are aging, females, urinary stasis, urinary retention, congenital or acquired factors?
The 4 types of assessments
What are initial/comprehensive, focused, emergency, and follow-up assessments?
Goals vs. Outcomes
What is
-Goals = reflect the problem, not measurable, start with "The patient will..."
-Outcomes = what we measure to determine if patient has achieved goals; derived from defining characteristics?
Three descriptors of a risk for nursing diagnosis
What is not based on a real problem, no signs/symptoms, and help patients prevent from developing problems?
Indwelling vs. Straight catheters
What are
1) Indwelling catheters are inserted with balloons to stay in, have 2 or 3 lumens
- Foley catheter = double lumen, one lumen is for urine and second is for balloon
- Triple lumen = continuous bladder irrigation OR when medications must be instilled into bladder
2) Straight catheters = used for intermittent or one-time bladder emptying
Indwelling catheter care
What are
-Insert catheters for appropriate reasons only
-Leave in for as long as needed only = ADVOCATE
-Use sterile technique
-Obtain unobstructed urine flow
-Empty drainage bag ¾ full
-Keep bag below bladder and off the floor
-Provide foley care at least once a shift?
The types of nursing diagnoses
What are problem-focused, risk, health promotion/wellness, and syndrome diagnoses?
Describe the 4 types of nursing assessments
What are
1) Initial/Comprehensive - baseline; informs us about changes that may occur during shift
2)Focused - focuses on main problem of patient
3) Emergency - Airway, Breathing, Circulation
4) Time-lapsed (Follow up) - used to see condition after time has passed; ex. after giving medication?
The main methods used to prioritize nursing diagnoses
What is Airway.Breathing.Circulation and Maslow's hierarchy?
Common urinary elimination problems (8) and brief descriptions of each
What are
1) Urinary retention - not completely emptying the bladder
2) Urinary stasis - having urine sit in the bladder
3) Urinary/bowel incontinence - not being able to control urination/bowel movements; accidents
4) Anuria - urine absence
5) Oliguria - little urine (#ogre)
6) Dysuria - painful urination
7) Urinary urgency - "I have to go NOW."
8) Urinary frequency - "I have to go too many times?"
Preventions of UTIs
What are
Teach young women to empty bladder after intercourse
Wear breathable undergarments
Showers are better than baths
Using white toilet paper than colored
Avoid soaps/ hygiene products that contain many perfumes because they can cause irritation and inflammation of urinary tract?