142 Test 3

a. Loss-the absence of an object, person, body part or function, or emotion that was formerly present.

i. actual
ii. perceived
iii. physical and psychological
iv. Anticipatory
v. Maturational

i. The emotional pain caused by a loss. It is a process and varies from person to person. Reactions to both grief and dying are similar.

ii. physiological
iii. psychosocial
iv. spiritual

i. Physiological
ii. Chest pain
iii. Emptiness in stomach
iv. Shortness of breath
v. Extraordinary fatigue
vi. Disrupted sleeping pattern
vii. Heavy sighing
viii. Aches and pains

1. feeling sad, down, or blue
2. -crying
3. -anger
4. -guilt
5. -withdrawal from others
6. -aimlessness
7. -loneliness
8. -apathy
9. -despair
10. -depression
11. -deteriorating self-care
12. -nightmares

1. -Death may cause people to question faith or reasons for living
2. -Why is God doing this to me?
3. -What did he do to deserve this?
4. -Why did I live when my loved one was taken away from me?
5. -How can I believe in a God that would allow so much pain?

a. The period of acceptance of loss and grief during which the person learns to deal with the loss.

a. The state of grieving that follows loss
b. Includes grief and mourning
c. Includes the inner feelings and outward reactions of the survivor
d. The bereavement period is not linear and does not proceed in sequential stages
e. Support groups help to facilitate the grief work that is needed to recover from the loss

1. Shock and Disbelief
2. Developing Awareness
3. Restitution
4. Resolving the Loss
5. Idealization
6. Outcome

a. Dysfunctional Grief is grief that is expressed to a significantly greater or lesser intensity over a significantly longer or shorter time than is culturally expected. It may manifest itself in serious physical and or emotional disabilities.

i. The difference between normal and dysfunctional grief is that the person experiencing dysfunctional grief is unable to adapt to life without the deceased person.

i. Absent or Unresolved Grief
ii. Inhibited or Converted Grief

i. Assess the clients’ and family’s knowledge, perceptions, and coping mechanisms.
ii. Determine where the family is in terms of the grieving process.

i. Anticipatory grief
ii. Dysfunctional grieving
iii. Chronic sorrow
iv. Normal grieving

i. The patient will:
1. Share Concerns with significant others and seek needed help
2. Express grief openly and progress through stages of grief
3. Accept the loss
4. Renew activities and relationships

i. Develop a trusting nurse-client relationship.
ii. Use therapeutic communication skills.
iii. Explain client’s condition and treatment.
iv. Teach self-care and promote self esteem.
v. Teach family to assist in care.
vi. Identify support system

i. Assess achievement of outcomes
ii. If outcomes not met-reassess the client and family
iii. Care of the Dying Client

i. Denial and isolation
ii. Anger
iii. Bargaining
iv. Depression
v. Acceptance

i. an illness in which death is expected within a limited space of time.

i. On client
ii. On family
iii. On the caregiver

1. Death is present when an individual has sustained either
a. irreversible cessation of circulatory and respiratory functions, or
b. irreversible cessation of all functions of the entire brain, including the brain stem.

a. inability to swallow
b. pitting edema
c. decreased GI and GU activities
d. bowel and bladder incontinence
e. elevated temperature with cold,clammy skin
f. cyanosis
g. lowered BP
h. noisy or irregular respiration
i. Cheyne-Stokes respiration
j. loss of motion, sensation, and reflexes

a. Heart-lung death
b. Whole brain death
c. Higher brain death

i. Pain and symptom management
ii. Clear decision making
iii. Preparation for death
iv. Completion
v. Contributing to others
vi. Affirmation of the whole person

a. Known as hospice care
b. Involves caring for the whole person

i. Advanced directives
ii. Assisted suicide
iii. Active euthanasia
iv. Do-not resuscitate or no-code orders
v. Organ donation
vi. Autopsy
vii. Comfort measures only
viii. Terminal weaning

i. allow individuals to record their wishes about end-of -life medical treatment. Patient Self-Determination Act of 1990 requires all hospitals to inform clients.
ii. Living wills
iii. Durable power of attorney for health care (www.DSAAPD.com)

i. violates ANA’S Code for Nurses and the ethical traditions of nurses

i. need physician order
ii. “slow code” -illegal
iii. become knowledgeable about the institution’s policy on DNR
iv. Passive Euthanasia

a. Developmental Considerations
b. Family
c. Socioeconomic status
d. Cultural influences
e. Religious influences
f. Causes of death

a. Identify personal losses that are influencing current state of well being and identify and use effective coping strategies
b. Communicate openly with clients about their losses and invite a discussion of the adequacy of their coping mechanisms.
c. Respond genuinely to concerns and feelings of dying clients and their families: do not be afraid to cry with client and to allow feelings to show
d. Value time spent with client and family members in which supportive presence is the primary intervention.

1. Client’s awareness of terminal nature of illness
2. Current stage of dying
3. Availability of support systems
4. Unfinished business expressed by client and family

1. Powerlessness
2. Helplessness
3. Hopelessness
4. Nursing Care of Dying Client

1. Schedule time to be available to client.
2. Respect the client’s confidentiality.
3. Offer to contact clergy.
4. Answer questions and provide information.
5. Make referrals as appropriate.
6. Nursing Care of Dying Client

1. meeting needs of dying clients and their families
a. physiologic needs
b. psychosocial needs
c. spiritual needs
d. family needs
e. learning needs
f. requests for suicide assistance

1. Nursing care plan is effective if:
2. dying clients meet the outcome of a dignified death
3. family members resolve their grief after an appropriate time of mourning and resume meaningful and active lives

1. Nurse prepares body for discharge.Review institution’s policy regarding post-mortem care.
2. Place body in normal anatomic position
3. Rigor Mortis effects-(stiffening of the body due to contraction of skeletal and smooth muscles) occurs in 2-4 hours. Close eyelids, insert dentures.
4. Replace soiled dressings and remove tubes.

1. Return personal items to family.
2. Complete postmortem care.

i. Nurse must continue to provide care to other clients. Offer support through the grief process.

i. After a client has died, the nurse provides support and care for the client’s family. Nurse should be an attentive listener.

a. Anticipatory grieving

a. Assessment
b. Nursing Diagnosis
c. Outcome Identification and Planning
d. Implementation
e. Evaluation

A clinical judgment about individual, family or community responses to actual or potential health problems/life processes.

i. the ANA and NANDA
ii.

1. “to distinguish”Or “to know”

an actual or potential health problem that can be prevented , or resolved by independent Nursing intervention

ii. --Data is analyzed
iii. --Client strengths and weaknesses are identified
iv. --Actual or Potential problems are identified

1. Focus on an injury, illness, or disease
2. Remains constant until a cure is effected
3. Physician directs the primary treatment

i. Cluster your data
1. --group of cues
2. --the cluster of cues helps you to make your inference
ii. Does your patient compare with or deviate from a Standard
1. --a norm or generally accepted rule
2. --includes patient strengths and patient problem areas
iii. Can you assign a meaning to these cues?

i. Actual
ii. Potential (Risk)
iii. Possible
iv. Wellness
v. Syndrome

i. validated by the presence of major defining characteristics.
ii. Label
iii. Definition
iv. Related factors (cause)
v. Defining characteristics (subjective or objective data)

1. physical (Pain)
2. sociocultural (Altered Parenting)
3. psychological (Anxiety, Fear)
4. spiritual disease (Spiritual distress)
5. illness or condition

i. Risk diagnosis are those that may occur.
ii. Example: Problem: Risk for falls
iii. Definition: Increased susceptibility to falling that may cause physical harm
iv. Related factors (cause): history of falls, left leg prosthetic, confusion
v. With a Risk Diagnosis there are no defining characteristics

i. Possible Diagnoses are those that the nurse suspects but has no supporting or defining data.

i. Assist the nurse to develop goals when working with an individual or family that is considered well, but might be able to move to yet a higher level of wellness

g. Syndrome Nursing Diagnosis
i. Syndrome:
1. a cluster of actual or risk Nursing Diagnosis that are present because of an event or situation

i. Describes patient’s health problem
ii. Can be identified from the NANDA list

i. Factors believed to be related as a cause or contributing factor
ii. Physical, emotional, sociologic, spiritual, environmental

i. Subjective/objective data that signal the existence of the problem

a. Establish priorities (Your patient will have more than one Nursing Diagnosis)
b. Identify patient outcomes
c. Select evidence based nursing interventions
d. Communicate plan of care

i. Setting priorities.
ii. Establishing patient outcomes: long and short term outcomes must be developed.
iii. Determining nursing interventions.
iv. Documentation and communication of the plan of care.

diagnostic reasoning and critical thinking skills. It is the role of the professional nurse alone to plan nursing care

i. prevention, reduction or resolution of the problem and attainment of the patient’s health expectation.

a. Make a problem list after completing the assessment.

v. High priority
1. pose the greatest threat
vi. Medium priority
1. not life threatening
vii. Low priority
1. not related to the problem
c. Prioritizing Need
i. Maslow

a. Necessary part of the planning phase
b. Informs patient, family and those involved with patient’s care about what is expected
c. Reduces misunderstandings by communicating your patient and family goals with the patient and the health care team

improvement or resolution of patient’s problem

i. Standardized classification of patient outcomes
ii. Established to help judge the success of nursing interventions
iii. Can be found in your Nursing Diagnosis text
iv. Outcomes are written as the opposite of the problem

the patient. These are not the nurses’ goals.

legally advisable and consistent with standards of practice.

resolution or improvement of the problem.

1. describe knowledge or intellectual behaviors

1. describe achievement or performance of a new skill

1. describe changes in patient values, beliefs, attitudes

1. Are Written to Achieve Long Term Goals
2. Short term outcomes are those that can be met relatively quickly, often in a few days or one day

1. are those that are to be achieved over a period of time, week(s) or after discharge
2. Short term outcomes must relate to long term goals

a. Resolution of the problem: solving of the problem so that it can be removed from the care plan
b. Improvement of the problem: outcome must reflect this clearly
c. Must include at least one long term outcome per nursing diagnosis

1. Legally Advisable and culturally appropriate
2. Must reflect standards of practice
3. Must not violate patient safety
4. Must be a therapeutic or beneficial goal

a. Describe
b. Perform
c. Verbalize
d. Walk
e. Cough
f. Demonstrate
g. Identify
h. List

a. Understand
b. Accept
c. Feel
d. Realize
e. Learn
f. Become aware
g. Will know

i. who is the person expected to achieve the outcome?

a. Subject:
i. who is the person expected to achieve the outcome?
b. Verb:
i. what actions must the person do to achieve the outcome?
c. Condition:
i. under what circumstances is the person to perform the actions?
d. Criteria:
i. how well is the person to perform action?
e. Time:
i. when?

g. Be realistic
h. Goal must state improvement or resolution
i. Include subject, verb, condition, criteria, time
j. Use measurable verbs
k. Be sure subject is patient or family
l. Whenever possible set goals mutually
m. Establish short and long term goals
n. Outcomes should reflect accepted standards of practice

a. Actions that are planned by the nurse to achieve the goal. Should enhance patient outcomes and be based on clinical judgment and knowledge

i. carrying out physician prescribed orders.

i. performed jointly by nurses and other members of healthcare team members .

nursing actions carried out without supervision or direction of another member of healthcare team.

i. format in which nursing care is standardized

i. process for nurses to expand their nursing knowledge and discuss effective strategies

a set of activities the nurse performs to carry out the intervention to achieve the goal

a. Consistent with plan of care
b. Based upon scientific principles
c. Individualized
d. Include assessments
e. Employ the blended skills
f. Used to provide a safe and therapeutic environment
g. Include teaching- learning opportunities
h. Use appropriate resources
i. Include independent nsg actions, MD initiated, & Collaborative interventions

13. Implementation

i. Updating data
ii. Documenting care
iii. Delegating care
iv. Communicating to members of the health care team through the patient care plan

a. Reassess patient to determine necessity of action
b. Develop a partnership with patient and family
c. Convey concern for what the patient is experiencing
d. Modify interventions to meet patients developmental and psychosocial background
e. Select interventions that are legally consistent with the Standards of Care
f. Use evidenced based research
g. Follow ethical/legal standards

a. Assess which tasks can be safely delegated
i. Delegate within state and institutional policies
ii. Delegate after the initial RN assessment is performed
b. Take frequent mini reports from the Unlicensed Assistive Personnel
c. Evaluate the UAP’s performance and the patients response

a. The Nurse Measures How Well the Patient Has Achieved Desired Outcome by evaluating the patient’s response to the outcome
b. Evaluate if your patient achieved the Planned Outcomes

c. Cognitive:
i. ask patient to repeat information or to apply new knowledge
d. Psychomotor:
i. ask patient to demonstrate new skill
e. Affective:
i. observe patient behavior
f. Physiologic:
i. perform physical assessment to evaluate physical changes in the patient

a. Continuous Quality Improvement Activities
b. Peer Review
c. JCAHO
d. State Board of Nursing
e. Nursing Audit

a. Terminate the plan of care
b. Modify the plan of care
c. Continue the plan of care

a. Aims to teach the care planning process in a step by step manner.
b. Provides opportunity to practice critical-thinking and decision-making skills.
c. Assists in improving written and verbal communication skills
d. Shows how to apply textbook and classroom knowledge to practice.

i. Nursing diagnosis
ii. Client goal
iii. Nursing interventions for each goal
iv. Incorporate NANDA, NIC AND NOC
viii. Using nursing care planning text

i. Appropriate assessments.
ii. Nursing orders/actions.
iii. Pertinent treatments.
iv. Pertinent medications
v. Patient teaching
vi. Nursing Diagnosis game

a. Provide a MEDIUM FOR TRANSPORTING nutrients to cells and wastes from cells, and transporting substances such as hormones, enzymes, blood platelets, and blood cells.
b. FACILITATE cellular metabolism and proper cellular chemical functioning.
c. Act as a SOLVENT for electrolytes and non-electrolytes.

i. Help maintain normal body temperature
ii. Medium for body secretions
iii. Facilitate digestion and promote elimination
iv. Act as a tissue lubricant

i. Relative amounts of fluid and electrolytes must be maintained within a narrow range within the fluid compartments

2/3- 3/4 of total body fluid

1. Intracellular
2. Extracellular
a. Interstitial
b. Intravascular

45-75%

a. Age
b. Body fat
c. Gender
d. Water Percentage of Body Weight

a. an atom or molecule carrying an electric charge

a. substances capable of breaking into electrically charged ions when dissolved in solution

a. positively charged ions

a. negatively charged ions

a. Regulation of water distribution
b. Transmission of nerve impulses
c. Clotting of blood
d. Regulation of acid-base balance

a. Sodium
b. Chloride
c. Potassium
d. Phosphate
e. Calcium
f. Bicarbonate
g. Magnesium

7. Sodium (Na+)

8. Potassium (K+)

9. Calcium (Ca+)

10. Magnesium (Mg+)

11. Chloride (Cl-)

b. Normal range is 96 to 106 mEq/L
c. Works with Na+ to regulate ECF volume
d. Promotes acid-base balance
e. Major component of gastric juice (HCl acid)
f. Found in salt, cheese, processed foods

12. Phosphate (PO4-)

b. Normal range is 2.5 to 4.5 mEq/L
c. Promotes bone and teeth rigidity
d. Helps maintain the body’s acid-base balance
e. Essential for the function of muscles, nerves, RBC
f. Found in whole grains, cereal, dry beans, and all animal products (meat, poultry, eggs)

13. Bicarbonate (HCO3)

a. Osmosis
b. Diffusion
c. Active transport
d. Filtration

a. Major method of transporting body fluids.
b. Water moves from less concentrated solution to more concentrated

concentration

a. Continual intermingling of molecules in liquids, gases or solids
b. Solutes move from area of higher concentration to area of lower concentration
c. CO2 and O2 exchange in lung’s alveoli and capillaries

a. Substances moving across a cell membrane from a less concentrated solution to a
i. more concentrated solution
b. Process particularly important in maintaining differences in Na and K ions.
c. Active transport = Moving uphill

a. Movement of fluid through a permeable membrane from an area of high pressure to one of lower pressure.
b. Involves fluid transport between vascular compartment and interstitial fluid

a. Colloid osmotic pressure-
b. Hydrostatic pressure-

i. holds fluid in vascular space
ii. Protein surround the large molecules and to not allow them to pass through membrane

i. force exerted by blood against arterial walls, pumping action of the heart creates this pressure

2500cc of fluid per day

1000 ml / day

approximately the same or balanced by their output

i. Thirst
ii. Kidneys
iii. Heart
iv. Lungs
v. Adrenal glands
vi. Pituitary glands

1. Osmotic and hydrostatic pressure changes force interstitial fluid into intravascular space
2. Cellular fluid is then drawn into depleted interstitial space
3. Result is cellular dehydration

1. Fluid and electrolytes gained and lost in equal proportions to the ECF

1. Diarrhea/vomiting
2. Draining wounds/fistulas
3. NG Suctioning
4. Paracentesis/thoracentesis
5. Infection, fever, diaphoresis
6. Diuretics
7. Extensive Burns

1. Decreased weight
2. Decreased urine output
3. Dry sticky mucous membranes
4. Flushed skin
5. Poor turgor
6. Weakness, confusion
7. Lower BP

a. Na is normal or increased
b. Hct increased
c. Elevated BUN

1. Report/document abnormal assessments
2. Offer fluids frequently
3. PRN meds for n/v
4. Report unbalanced
5. I & O
6. Daily Weight
7. Maintain IV fluids
8. Patient teaching
9. Small frequent feedings
10. Save/report all urine output
11. Ask for medications to relieve symptoms

a. Isotonic imbalance
b. Exessive retention of fluid and sodium in the extracellular fluid compartment
c. Increased sodium in interstitial space causes fluid to be pulled from cells to equalize the tonicity
d. Fluid is pulled from cells to interstitial space
e. Cells are dehydrated

1. Lower, dependent body parts
2. Feet, legs, sacrum
3. Can account for up to a 10 pound weight gain
4. May be relieved by elevating the part

1. leaves a pit or depression after finger pressure

1. Renal disease
2. Decreased cardiac output (pump)
3. Cirrhosis of liver (hardening)
4. Hormonal imbalances

i. Decreased output
ii. Increased weight
iii. Taut shiny skin
iv. Edema
v. Bounding pulse
vi. Respiratory distress
vii. Elevated BP
viii. Distended neck veins: JVD

i. Careful I and O
ii. Daily Weights
iii. Monitor edema-skin care
iv. Elevate extremities- (be aware of cardiac status!)
v. Auscultate heart/lung sounds
vi. Pulse ox
vii. Ensure that 02 is properly connected
viii. Conserve strength
ix. Administer diuretics as ordered
x. Monitor/restrict dietary sodium intake as indicated

1. low sodium diet, diuretics

1. anorexia, lethargy , fatigue, nausea, vomiting, confusion, MUSCLE CRAMPS, TWITCHING AND SEIZURES.

1. Monitor I&O, monitor serum Na level, address safety issues, seizure precautions

1. dehydration, increased intake, excessive IV infusion, renal failure

thirst, elevated body temperature, dry sticky membranes, disorientation, lethargy , seizures, coma

1. monitor I&O & VS, observe for high intake of sodium rich foods, monitor for restlessness, disorientation

1. Diet deficiency, diarrhea, loss of GI fluids, steroid use ,diuretics

1. Anorexia, fatigue, ARRYHTHMIAS, increased sensitivity to digitalis, muscle weakness, tender muscles, EKG CHANGES

1. assess digitalized patients, encourage extra K+ intake, educate about use of laxatives and diuretics, monitor heart if necessary, administer potassium po or IV

1. increased oral or IV intake, renal failure, shift of potassium out of cells

Vague muscle weakness, cardiac arrhythmias, GI symptoms, parasthesias & tender muscles

1. Monitor labs, follow rules for safe administration of K+, educate about foods high in K+, K exalate enemas.

1. Diet deficiency, Vit. D deficiency, malabsorption, hypoparathyroidism , acute pancreatitis,

1. Numbness and tingling of toes and fingers, muscle spasms and cramps, seizures, mental changes, and EKG changes.

Observe for seizures, protect airway, watch for arrhythmias and EKG changes. Maintain safety, educate about calcium rich foods

1. increased intake of milk, calcium based meds or Vitamin D, magnesium antacids, increased bone loss from immobilization

1. muscle weakness, tiredness, lethargy, renal stones, polyuria, diarrhea, decreased memory, cardiac arrest

1. Monitor vital signs, EKG rhythms encourage activity, increase oral intake, be alert for digoxin toxicity, encourage rest periods

1. Renal Failure, adrenal insufficiency, excessive administration of magnesium during eclampsia.

1. Hypotension, flushing of skin, drowsiness, hypoactive reflexes, muscle weakness

1. Monitor vital signs, reflexes, provide rest periods, address safety in ADL’s

1. chronic alcoholism, intestinal malabsorption, diarrhea, NG suctioning, drug therapy

1. Neuromuscular irritability, increased reflexes, ARRYTHMIAS, mental changes, hypertension

iii. Monitor vital signs, heart, LOC, reflexes, safety issues

i. the homeostasis of the hydrogen ion concentration in body fluids

i. a substance that donates hydrogen ions

i. a substance that accepts hydrogen ions

i. Respiratory Alkalosis (Carbonic Acid Deficit)
ii. Respiratory Acidosis (Carbonic Acid Excess)
iii. Metabolic Acidosis (Bicarbonate Deficit)
iv. Metabolic Alkalosis (Bicarbonate Excess)

1. Respiratory Regulation of Acid-Base Balance
2. Renal Control of Hydrogen Ion Concentration

i. ABG Element Normal Value Range
ii. pH 7.35 to 7.45
iii. Pa02 90mmHg (80 to 100 mm Hg)
iv. Sa02 93 to 100%
v. PaC02 40mmHg (35 to 45 mm Hg)
vi. HC03 24mEq/L (22 to 26mEq/L)

i. Thirst
ii. Renal function
iii. Fluid and dietary intake
iv. Fluid status (turgor, MM’s, vein distention, edema)
v. BP changes
vi. Weight ( #1 indicator in change)
vii. Urine pH and specific Gravity
viii. Serum electrolytes
ix. Fatigue
x. Muscle weakness
xi. Nursing Diagnosis
xii. Impaired Gas Exchange
xiii. Decreased Cardiac Output
xiv. Risk for Infection
xv. Altered Oral Mucous Membrane
xvi. Activity Intolerance
xvii. Ineffective Breathing Patterns
xviii. Impaired Urinary Elimination
xix. Knowledge Deficit

a. Modify fluid balance
b. IV Therapy
c. Monitor electrolytes
d. Dietary Balance
e. TPN if indicated
f. Tube Feed as indicated
g. I & O
h. Guard against insensible loss
i. Oxygenation
j. Treat underlying condition
k. Electrolyte replacements
l. Monitor blood glucose
m. Daily weight
n. Vital signs
o. Teaching as appropriate
p. Guard skin integrity

a. Work as member of interdisciplinary Team
b. Ongoing Evaluation Considerations
i. Labs
ii. ABG’s
iii. Daily Weights (most accurate indicator of fluid status)
iv. I & O
v. Physical Assessment
vi. Dietary and Fluid Adherence
vii. Teaching effectiveness

is 135-145 mEq/L

maintain water balance throughout the body

the volume and distribution of the ECF

nerve impulses and promotes muscle contraction

table salt, cheese, processed foods

is 3.5 to 5mEq/L

contraction of skeletal and smooth muscle
aka: cardiac rhythm

acid-base balance by cellular exchange of hydrogen ions

bananas, oranges, dried fruits

strength and durability to teeth and bones

transmission nerve impulses, neuromuscular activity, and blood clotting

milk, cheese, leafy vegetables, dried peas and beans and fortified beverages

neuromuscular activity

the enzymes and B vitamins and the use of K+, Ca+, and protein

green leafy vegetables, whole grains, fish, chocolate, cocoa, nuts, dried peas and beans

bone and teeth rigidity

the body’s acid-base balance

muscles, nerves, RBC

whole grains, cereal, dry beans, and all animal products (meat, poultry, eggs)

c. that regulates acid-base balance as a component of the carbonic acid-bicarbonate buffering system

through metabolism to meet the body’s needs

a. Data collected during the assessment are critically analyzed and interpreted.
b. Data collected helps the nurse identify patient strengths and health problems.
c. The RN analyzes the assessment data to determine the diagnosis or issues.