NC1 final for Excelsior #2

essential for evaluation, review, and future planning. nse's signature demonstrates accountability

"nursing dx","goals or desired outcomes", nursing interventions", "evaluation".

for example Turn and repositon q2h instead of turn and reposition every two hours.

shifts can be 8 hours or 12 hours. witing orderes needs to have specific times and not q shift

for steps of care such as trach care, write see procedure book instead of writting out all steps

reinforces clients individuality and sence of control

for example, active range of motion to affected limbs q2h. prevents contractures and maintains muscle strength

for example, inspect incision q8h

for example, PT OT ST or nutritionist consult

often necessary to consult and make arrangements with community health nurse, social worker,and specific agencies that supplythat supply client info and eqipment. add teaching and discharge planning as an addendaif are lengthy and complex.

1 set priorities
2 establish desired goals and patient outcomes
3 selecting nursing interventions
4 writing nsg orders

subject, verb, conditions or modifiers,criterion for desired performance

date, action verb, content area, time element, signature

intellectual skills

all activities, verbal and nonverbal, people use when interacting directly with one another.

hands on skills

continuous

consists of conclusion and supporting data. statement that goal was met, partially met or not met.

pain, swelling, redness, heat and impaired function

fever, elevated pulse,elevated respirations, malaise, loss of energy, anorexia, n&v, enlarged and/or tender lymph nodes. leucocytes > 11,000, elevated ESR.

absence of bleeding or clots binding the edges, inflammation at wound edges at first then decrese in inflammation as clot deminishes, scar formation, diminished scar over peiod of months to years.

interpersonal relationships or interpersonal relationships

similar to planning phase prior to an interview. nurse has some limited information

orientation phase or prehelping. sets tone for the rest of the relationship. client may display some resistive behaviors

nse helps client explore thoughts, feelings, actions and helps the client plan a programor action tomeet preestablished goals

normal is prescence of normal skin and skin layers uniterrupted by wounds. skin integrity is first line of defense against infection.

clients full name, date and time order was written, name of drug to be administered,dosage of med route of admin, signature of Dr or nurse making drug request.

micro-organism free area

all articles are sterile with the field,always check package for intactness, check expiration date, storage areas needs to be clean, dry, off the floor and away from sinks.

handle sterile objects that will touch open wounds or enter body cavities only with sterile forcepts or sterile gloves

once left unattended field in unsterile, do not turn back to sterile field, only front part of sterile gown from waist to shoulders and 2in above the elbowsto the cuff of the sleeve is condiered sterile, keep sterile gloves above waist and in sight and only touch sterile things, once a sterile field becomes unsterile, it must be set up again before proceeding.

moving air can carry dust particles and microorganisms, keep doors closed and traffic to a minimum, keep areas clean by damp cleaning with a germicide, keep hair clean and contained to keep it from falling into a sterile field, wear surical caps in OR, no sneezing or coughing over sterile field, nse with URI needs to refrain from doing procedures, keep talking to a minimum over a sterile field, do not reach over a sterile field

always hold forceps with the tips below the handles, after surgical hand washing, hold hands higher than the elbows.

sterile moisture proof barriers are used beneath sterile objects, keep sterile covers on sterile containers dry, replace sterile field when they become moist

a 1 inch margin at each edge of an open drape is considered unsterile because the edges are in contact with unsterile surfaces

use sterile gloves or sterile forceps to handle sterile items, wash hands to reduce number of microrganisms

when an object becomes unsterile it does not necessarily change in appearance, person who sees an object become unsterile must correct or report situation do not set up a sterile field ahead of time or future use

increases capillary permeability, increases cellualr metabolim increases inflammation sedative effect, vasodilation. softens exudateincreases blood flow to specific area bringing oxygen, nutrients, antibodies an leukocytes.

time required for the elimination process to reduce the concentration of a drug to one- half what ot was at initial administration

PASS- Pull pin, Aim, Squeeze, Sweep

occurs when the body loses both water and electrolytes.goals include maintain or restore fluis balance, maintain or restore normal balance of electrolytes in the intracellular and extracellular compartments, maintain or restore pulmonary ventilation and oxygenation, prevent associated resks ( tissue breakdown, decreased cardiac output, confusion, other neurolgic signs).

occurs when a person is unable to process or manage the amount or intensity of sensory stimuli. imterventions can include minimizing unnecessary distraction, control pain, introduce self by name and address client by name, provide orientation cues, provide a private room, limit visitors, plan care to allow for uninterrupted periods of sleep and rest speak in a low tone and in a unhurried mannor, provide new info gradually, describe procedure and tests before hand. reduce noxious odors, take time to duscuss clients problems, assist client with stress reducing techniques