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FUNDAMENTALS OF NURSING
CH 19 Implementing Nursing Care
7
Nursing
Undergraduate 1
12/09/2012

Additional Nursing Flashcards

 


 

Cards

Term
Nursing Intervention 
Definition
Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes 
Term
Direct care 
Definition
Treatments performed through interaction w the patient. For example, a patient may require medications administration, insertion of an intravenous infusion or counseling during a time of grieft
Term
Indirect Care 
Definition
Treatments performed away from the patient but on behalf of the patient or group of patients.
Term
A clinical guideline 
Definition
Term
Patient adherence 
Definition
Term
Definition

PRIMARY HEALTH PROBLEM: radical prostatectomy

PRIORITY ASSESMENTS: condition of wound, level of comfort, knowledge of care requirements when discharged,ability to manage home care, and emotional response to changes from surgury 

 

Nursing Diagnosis: acute pain related to incisional trauma 

  • Winces when incision is palpated
  • Acknowledges pain over incision 
  • Rates discomfort a 7 on a scale of 0 to 10
  • Asks if pain medicine is available
Interventions:
-administer analgesic routinely as ordered
-teach progressive relaxation 
-use a calm approach 
-have patient splint incision when moving 

Nursing Diagnosis: impaired physical mobility related to incisional pain

  • Has not turned since some time last night 
  • Lies flat in bed w muscles tensed 
  • Reports discomfort of incision 
Interventions:
-administer pain medicine every 30 minutes before turning and ambulation
-Teach progressive relaxation 
-explain importance of becoming mobile after surgery 


Nursing diagnosis: deficient knowledge related to inexperience w surgery 

 

  • Requests information about postoperative care
  • Has no knowledge about postoperative wound care 
  • Ask questions 
  • Has no previous experience w wound care 
Interventions:
-explain and demonstrate catheter and wound care
-include wife in instruction sessions 
-discuss signs of wound infection
-explain activity restrictions to follow when discharged
 

Nursing diagnosis: anxiety


  • States, "I am worried about me and my wife" 
  • States, "doctor told me surgery could change our ability to have sex" 
  • States, "I have a friend who died from cancer" 
  • Has uncertainty 
  • Has poor eye contact 
Interventions:
-use a calm, reassuring approach in discussions 
-have patient verbalize his perceptions, feelings, and fears -discuss concerns w Mr. Jones and Mrs. Jones together 
-consult w surgeon regarding implications of surgery
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