ATI - Chapter 7 Flashcards
The nursing process is a cyclical, critical thinking process that consists of ____ steps to follow in a purposeful, goal directed, systematic way to achieve optimal client outcomes.
5
The nursing process is a variation of scientific reasoning that helps nurses organize nursing care and ____ the optimal available evidence to care care delivery.
apply
The ____ is a dynamic, continuous, client-centered, problem-solving, and decision-making framework that is foundational to nursing practice.
nursing process
The nursing process provides a framework throughout which nurses can apply knowledge, experience, judgement, and skills, as well as ______ of nursing practice to the formulation of a plan of nursing care.
established standards
The nursing process helps nurses integrate critical thinking creatively to base ______ on reason.
nursing judgements
The nursing process promotes the _____ of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.
professionalism
The nursing process includes sequential but overlapping steps (5)
assessment/data collection analysis/data collection planning implementation evaluation
The accuracy and _____ of assessment/analysis/data/collection and planning have a direct impact on implementation and evaluation
throroughness
Use of the nursing process results in a comprehensive, individualized, client-centered plan of nursing care that nurses can deliver in a ______ and reasonable manner.
timely
_______ collection involves the systematic collection of information about clients’ present health status to identify needs and additional data to collect based on findings.
assessment/data collection
Nurses can collect data during an initial assessment (_______), focused assessment, and ongoing assessments.
baseline data
Methods of data collection include observation, __________, medical history, comprehensive or focused physical exams, diagnostic and laboratory reports, and collaboration with other members of the health care team.
interviews with clients and families
To collect data effectively, nurses must ask clients appropriate questions, listen carefully to responses, and have excellent _______ skills.
head to toe physical assessment
Nurses also must employ clinical judgment and critical thinking in accurately ______ when to collect assessment data. They also must recognize the need to collect assessment data prior to interventions.
recognizing
Nurses collect ______ during a nursing history. They include clients’ feelings, perceptions, and descriptions of health status. Clients are the only one who can describe and _____ their own symptoms.
subjective data
verify
Nurses observe and measure objective data (signs) during a physical exam. They feel, see, hear, and ____ objective data through observation or physical assessment of the client.
smell
During this assessment/data collection, the nurse validates, interprets, and ______.
clusters data
Documentation of the assessment data must be thorough, concise, and ____.
accurate
My shoulder is really sore.
subjective or objective
subjective
The client grimaces when attempting to brush her hair with her left arm.
subjective or objective
objective observation
Analysis/data collection requires nurses to look at the data and recognize _______.
patterns or trends
Analysis/data collection requires nurses to compare the data with expected standards or ____. Arrive at conclusions to guide nursing care.
reference ranges
RNs make multiple analyses based on their interpertations of collected data. They decide, using reasoning and judgement, which data account for clients’ health status or ______.
problems
When planning client care or contributing to a client’s plan of care, nurses must establish ______ and optimal outcomes of care they can readily measure and evaluate.
priorities
The established priorities and outcomes of client care then direct nurses in selecting interventions to include in a plan of care to promote, _____, or restore health.
maintain
Nurses do three types of planning. Initially they develop a ______ plan of care for clients based on comprehensive assessments they complete, for example, on admission to health care facility or to a home health organization.
comprehensive
Nurses do ____ planning through the provision of care. While obtaining new info and evaluating responses to care, they modify and individualize the initial plan.
ongoing
____ planning is a process of anticipating and planning for clients’ needs after discharge. To be effective, discharge planning must begin during admission.
discharge
Throughout the planning process , nurses set priorities, determine client outcomes, and select specific nursing _____.
interventions
Nurses participate in priority setting when thyey identify a preferential order of problems. This guides the delivery of nursing care. They can use guidelines to set priorities, such as _______.
Maslow’s hierarchy of basic needs.
Nurses work with clients to identify _____, where as outcomes identify the observable criterion that will determine success or failure of the goal.
goals
The goal must be ______, singular, observable, measurable, time-limited, mutually agreeable, and reasonable.
client-centered
Concise, ______ goals helps nurses and clients evaluate progress through both short and long term goals to guide the client toward the ______ and determine the effectiveness of nursing care.
measurable
planned outcome
________ interventions are when nurses use evident and scientific rationale to take autonomous actions to benefit clients. They base these actions on identified problems and health care needs, and make sure they are within their scope of practice. Nurses perform or delegate the interventions and are accountable for them.
nurse initated/independent interventions
__________ are interventions nurses initiate as a result of a provider’s prescription or the facility’s protocol, such as blood administration procedures.
provider-initiated/dependent interventions
______ interventions are carried out by nurses in collaboration with other health care team professionals.
collaborative interventions
The _____ is the end product of the planning step. Nurses organize the ____ for quick identification of problems, outcomes, and interventions to implement.
Nursing Care Plane
NCP
During implementation the nursing process, nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the _____.
nursing process
During implementation, they must use problem-solving, clinical judgment, and critical thinking to select and implement appropriate _______ using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain or restore health.
therapeutic interventions
Therapeutic interventions also include measures nurses take to minimize risk, such as wearing personal protective equipment. Nurses intervene to respond to unplanned events, a change in status, or the ______ of a life threatening situation.
emergence
Nurses use evidence-based rationale for the selection and implementation of all _____. Caring and professional behavior should be at the center of all therapeutic nursing interventions
therapeutic interventions
During implementation, nurses perform nursing actions, delegate tasks, supervise otehr health care staff, and document the care and _____.
client’s responses
During the evaluation stage, nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the ______ and outcomes.
goals
Nurses continuously evaluate the client’s progress toward outcomes, and use the client data to determine whether or not to _____ the plan of care.
modify
Nurses determine the ________ of the nursing care plan. They collect data based on the outcome criteria then compare what actually happened with the planned outcomes. This helps determine what further actions to take.
effectiveness
Factors That can lead to lack of goal achievement
an incomplete database
unrealistic client outcomes
nonspecific nursing interventions
inadequate time for the client to achieve the outcomes
Client outcomes in specific, measurable terms are easier to ____.
evaluate
