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1030 Fundamental > 1030 Unit 1 Nursing Process > Flashcards

1030 Unit 1 Nursing Process Flashcards

1
Q

What are the 4 ways to define “critical thinking”?

A
  • Responded thinking
    -Openness to alternatives
  • Reflection
  • Evidence-based practice
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2
Q

What does A.D.P.I.E. mean w/ the nursing process?

A

A= assessment
D= diagnosis
P= planning
I= Implementation
E= Evaluation

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3
Q

Describe the “assessment” in the nursing process.

A

-Collection of objective and subjective data.
-Consider the situation.
-Collect & process the information.

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4
Q

Define “diagnosis” as used in the nursing process.

A

-Determine the client’s priority
-Identify concerns

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5
Q

Describe “planning” in how its used in the nursing process.

A

-Set smart goals to ensure the client achieves a positive outcome.

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6
Q

Define “implementation” and how its used in the nursing process.

A

Take action to provide nursing care.

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7
Q

What are the 5 reasons we do an assessment?

A

1) Establish baseline pt condition.
2) Judge what the pt can do, who safe they are.
3) Determine pt needs.
4) Determine if condition needs to be reported to the Provider.
5) Plan and deliver pt-centered care.

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8
Q

What are the 4 types of assessments?

A

1) Initial (comprehensive)
2) Focused (specific)
3) Emergent (Life-Threatening)
4) Ongoing (Re-evaluation)

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9
Q

How does a nurse collect data during an assessment?

A

1) Collecting, organizing validating, & documenting client data.
2) Observation
3) Interviews
4) Nursing assessment

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10
Q

What is subjective data in an assessment w/ examples?

A
  • Information that is only known to the pt and family members.
  • “I can’t breathe”
    -Pt reported feeling dizzy when standing.
  • Pain 3/10
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11
Q

Define objective data in regards to an assessment w/ examples.

A
  • Those things that you can observe through your senses of hearing, sight, smell and touch.
    -It provides a description of what you observe but they don not involve drawing a conclusion.
    Ex:
  • BP, HR
    -Pt is red and flushed
  • Pt is tearful
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12
Q

What is “recognize cues” used for?

A
  • Identify relevant and important information from different sources (medical history, vs).
  • You don’t need to connect cues w/ hypotheses just yet.
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13
Q

Where is this used in the nursing plan: Identify problems that can be prevented or resolved by interpreting and analyzing the data.

A

Diagnosing

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14
Q

Where is this used in the nursing plan: Develop a prioritized list of pt problems.

A

Diagnosing

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15
Q

Where is this used in the nursing plan: Nursing diagnoses give logical reasoning to the pt’s conditions and ways to improve their condition.

A

Diagnosing

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16
Q

Define “analyze cues” in the diagnosing process.

A
  • Organizing and linking the recognized cues to the client’s clinical presentation.
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17
Q

What are some questions you should ask when analyzing cues.

A

1) What client conditions are consistent with the cues?
2) Why is a particular cue or subset of cues of concern?
3) Are there cues that support or contraindicate a particular condition?
4) What other information would help establish the significance of a cue or set of cues?

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18
Q

What are the ABCs of prioritization?

A

A: Airway
B: Breathing
C: Circulation

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19
Q

What 3 attributes are essential for survival in prioritization?

A

ABCs
Airway
Breathing
Circulation

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20
Q

When prioritizing a pt who comes in what should problems should you care for first?

A

Recognize and stabilize the client’s most critical issue first.

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21
Q

What do nurses do to help pts according to Maslow?

A
  • Pts need help addressing physiological needs of survival first, then the needs related to relationship issues in the love and belonging tier.
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22
Q

What is Maslow’s Hierarchy of Human Needs first level? describe.

A

The first level is composed of physiological needs or those needed to survive.
Food Air
Water Temp regulation
Elimination Sex
Rest Physical activity

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23
Q

What is Maslow’s Hierarchy of Human Needs second level? describe.

A

The second level addresses safety and security needs; things a human need to remain alive and protected.
Protection Order
Law Stability
Shelter
Emotional & physical safety and security

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24
Q

What is Maslow’s Hierarchy of Human Needs third level? Describe.

A

The third level is the need for love and belonging.
Giving & receiving affection
Meaningful relationships
Belonging to groups

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25
Q

What is Maslow’s Hierarchy of Human Needs fourth level? Decribe

A

The fourth level is the need for self-esteem and feeling of self-worth.
Pride
Sense of accomplishment
Recognition by others

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26
Q

What is Maslow’s Hierarchy of Human Needs fifth level? Describe.

A

The fifth level addresses cognitive needs for learning and exploring.
Knowledge understanding
Exploration

27
Q

What is Maslow’s Hierarchy of Human Needs sixth level? Describe.

A

The sixth level is composed of aesthetic needs for beauty and order.
Symmetry Order
Beauty

28
Q

What is Maslow’s Hierarchy of Human Needs seventh level? Describe.

A

The seventh level addresses the need for self-actualization or reaching one’s own growth potential.
Personal growth
Reaching potential

29
Q

What is Maslow’s Hierarchy of Human Needs eight level.

A

Level Eight is that of transcendence or the need to help others reach their highest potential.
Of self
Helping others self-actualize

30
Q

What do nursing diagnoses address?

A

Physical, psychosocial, & environmental needs of pts, w/ some of them being a higher priority than others.

31
Q

What is considered primary data?

A

During the interview, the information provided by the pt.

32
Q

What is considered secondary data?

A

During the interview, information obtained from the family members, friends and the pt’s chart.

33
Q

What is rapport?

A

Creating a relationship or mutual trust and understanding w/ a pt when you first enter their room.

34
Q

How do you create rapport w/ a pt?

A
  • By introducing yourself and explaining your role in the pt’s care.
  • By telling the pt the purpose of the interview and the approximate length of time it will take.
35
Q

How does a nurse prioritize a hypotheses?

A
  • Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time.)
36
Q

What questions do nurses have when prioritizing a hypotheses?

A
  • Which explanations are most/least likely?
    -Which possible explanations are the most serious?
37
Q

How does a nurse plan in A.D.P.I.E.

A

-Expect pt needs
-Generate solutions

38
Q

How does a nurse plan for expected pt needs?

A
  • Pt centered
  • Singular goal or outcome
  • Observable
  • Clear & concise
  • Mutually agreed to by pt and nurse
39
Q

When a nurse in the “plan” phase, what 2 things does she do to generate solutions?

A
  • Identifying expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
    -Focus on goals and multiple potential interventions - not just the best one- that connect to these goals. Potential solutions could include collecting additional information.
40
Q

Define independent intervention.

A
  • Initiated by the nurse who acts independently.
41
Q

When would a nurse use a independent intervention?

A

Nursing interventions for activities such as ADL’s, health education, health promotions.

42
Q

Define interdependent interventions

A

-Collaborate interventions
-Multidisciplinary

43
Q

Why would a nurse use a interdependent intervention.

A

Nurses are often the eyes and ears of the rest of the healthcare team.

44
Q

Define dependent interventions.

A

-Physician-initiated interventions
-Carrying out the physician’s order - but still accountable.

45
Q

When would you use a dependent intervention?

A

To carry out the physician’s order - but still accountable.

46
Q

Define protocols/standing orders or clinical/critical pathways.

A

Allow nurses to execute nursing activities in specific situations.

47
Q

What are types of protocols/standing orders or clinical/critical pathways?

A

OB admits
Bowel programs
PCA, pain management

48
Q

Define implementation in the A.D.P.I.E

A

1) Take action

2) Implementing the solution(s) that addresses the highest priorities.

49
Q

What questions should you ask yourself when in the Implementation stage of nursing assessment.

A

1) which intervention or combination of interventions is most appropriate?

2) How should the interventions be accomplished (performed, requested, administered, communicated, taught).

50
Q

Define the Evaluate stage of the nursing assessment.

A

1) evaluate outcomes
2) Comparing observed outcomes against expected outcomes.

51
Q

What questions should you ask when in the Evaluation stage of the assessment?

A

1) What signs point to improving/declining/unchanged status?

2) Were the interventions effective?

3) Would other interventions have been more effective?

52
Q

Define the Intervention stage of the nursing assesment?

A

-1) Plan interventions by prioritizing care, rationale, coordinate care, collaborative effort, evidence based.

53
Q

How do you prioritize care?

A

What is realistic, safe, and pt-centered.

54
Q

How do you rationale interventions?

A

It lies within established standards of care, nurse practice act, policies and procedures.

55
Q

Who dose a nurse collaborate effort with?

A

Pt
Peers
other healthcare professionals

56
Q

What is evidence-based interventions based on?

A

Based on science

57
Q

Why does a nurse do a physical assessment?

A

In acute care settings, they perform to collect additional data used in formulating nursing diagnoses according to facility policy and the state Nurse Practice Act.

58
Q

How is a physical assessment usually performed?

A

Head-to-toe pattern to avoid omitting any important data.

59
Q

Define inspection:

A

The visual examination of the pt’s body for rashes, breaks in the skin, normal appearance of eyes, ears, nose, mouth, limbs, and genitals.

60
Q

What is palpation:

A

The touching or feeling the torso and limbs for pulses, abnormal lumps, temp., moisture, and vibratoins.

61
Q

What is auscultation

A

Listening for abnormal sounds in the lungs, heart, or bowels.

62
Q

What is percussion

A

using tapping movements to detect abnormalities of the internal organs.

63
Q

What should outcome statements include?

A

1) Realistic, specific action to be taken by the pt (not the nurse).

2) An action that the pt is willing and able to perform.

3) An action that is measurable.

4) A definite time frame for the action to have been accomplished.

64
Q
A

1030 Fundamental (4 decks)

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