221 Exam #2 Flashcards
What are the four pieces of the full-spectrum nursing process?
Thinking, doing, caring, patient situation
The following are a part of which aspect of full-spectrum nursing:
- Critical thinking
- Theoretical knowledge
Thinking
The following are a part of which aspect of full-spectrum nursing:
- Practical knowledge
- Nursing process
Doing
The following are a part of which aspect of full-spectrum nursing:
- Self-knowledge
- Ethical knowledge
Caring
The following are a part of which aspect of full-spectrum nursing:
- Patient data
- Patient preferences
- Context
Patient situation
What is critical thinking in simple terms?
Integration of knowledge, skills, & experiences
What are the three primary components of theoretical knowledge?
Principles, theories, & known facts
What is ethical knowledge?
Knowing your obligations, sense of right vs. wrong
What are the three primary components of patient data?
Physical, psychosocial, spiritual (holism)
What is the context component of patient situation in the full-spectrum nursing model?
Where & how care is happening
What is the difference between the medical assessment and the nursing assessment?
Medical assessment: focus on disease & pathology (ex. Patient has CHF)
Nursing assessment: focus on patient’s response to illness or health problem (ex. Patient has altered breathing pattern & fluid volume overload)
Which 3 aspects of assessment can be delegated by a professional work to nurse aid/unlicensed assistive personnel?
Vital signs
Pain reports
Fingerstick blood glucose
Tasks can’t involve assessment, interpretation, or independent decision making during implementation or at completion
Which aspects of assessment must be conducted by a professional nurse?
- Interview
- Physical assessment
What does a professional nurse have to do in order to be able to delegate to a nurse aid/unlicensed assistive personnel?
- Assign the task
- Validate the collected data
When an RN delegates a task to a UAP, who assumes responsibility accountability for said task?
The RN
Which three resources should a RN consult for clarification related to delegation?
- State’s nurse practice act
- American Nurses Association (ANA) scope & standards of practice
- Accrediting agencies
What are the six steps of the nursing process in order?
- Assessment
- Diagnosis
- Planning outcomes
- Planning interventions
- Implementation
- Evaluation
What does the assessment (1) stage of the nursing process entail?
Gathering data
What does the diagnosis (2) stage of the nursing process entail?
Identifying patient health needs
What does the planning outcomes (3) stage of the nursing process entail?
Identifying goal you want to achieve through nursing actions (one short-term, one long-term)
What does the planning interventions (4) stage of the nursing process entail?
Determine how to help patient achieve stated goal(s)
What does the implementation (5) stage of the nursing process entail?
Putting plan into action
What does the evaluation (6) stage of the nursing process entail?
Judging whether or not plan was successful- whether or not patient goal(s) were met
What differentiates subjective and objective data?
Subjective: data reported by patient
Objective: measurable data
What is theoretical nursing e /?
Give an ex
The “why” behind nursing practices
What is theoretical nursing knowledge?
Give an example relating to oxygenation
The “why” behind nursing practice
Ex. Room air is 21% oxygen
What is practical nursing knowledge?
Give an example relating to oxygenation
The “doing” portion of nursing practices
Ex. Placing a nasal cannula to increase a patient’s oxygen levels
What is self nursing knowledge?
Awareness/reflection of personal beliefs, biases, etc.
What is a comprehensive nursing assessment?
Head-to-toe assessment that evaluates patient’s overall health, admission history
What is a focused nursing assessment?
What are the two types of focused assessment?
Assessing for data specific to an identified or suspected issue (usually body part/ability focused)
Initial focused, ongoing focused
What differentiates an initial focused assessment and an ongoing focused assessment?
Initial focused: assessing a specific patient complaint for the first time
Ongoing focused: assessing the same specific patient complaint on multiple occasions
What is the reason for writing & developing goals for a patient?
To identify the change we want to see in the patient’s condition
What differentiates independent and dependent nursing interventions?
Independent nursing intervention may be done without a doctor order, but dependent nursing intervention requires a doctor order
What is ongoing evaluation?
Evaluation that is done overtime until patient goal is met
What is intermittent evaluation?
Evaluation done at specific times
What is terminal evaluation?
Evaluating if patient goal has been met in order to remove them from the care plan pertaining to said goal
What does the S.M.A.R.T. goal mnemonic stand for?
S- specific
M- measurable
A- attainable/achievable
R- relevant
T- timely
What are the 5 components of the “specific” portion of S.M.A.R.T. goals?
- Who is involved? (Usually patient)
- What do you want to accomplish?
- Where will it be done?
- Why will it be done?
- Constraints and/or requirements
What are the 2 components of the “measurable” portion of S.M.A.R.T. goals?
- Can progress be tracked & outcomes measured?
- How will I know that the goal has been accomplished?
What is the “attainable” portion of S.M.A.R.T. goals?
Is the goal reasonable enough to be accomplished? How?
(neither below standard practice or out of reach)
What are the 2 components of the “relevant” portion of S.M.A.R.T. goals?
- Is the goal worthwhile & will it meet patient needs?
- Is each goal consistent w/ other established goals & does it fit w/ both immediate & long-term plans?
What is the “timely” portion of S.M.A.R.T. goals?
Include a time limit for goal to establish urgency when needed & to promote good time management
Put the following tiers of Maslow’s Hierarchy of Needs in order starting w/ the needs that must be addressed first:
- Aesthetic
- Love & belonging
- Transcendence
- Physiological
- Safety & security
- Self-esteem
- Cognitive
- Self-actualization
- Physiological
- Safety & security
- Love & belonging
- Self-esteem
- Cognitive
- Aesthetic
- Self-actualization
- Transcendence
