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Nursing - 115 > Care Plan/Concept Map - Unit 4 > Flashcards

Care Plan/Concept Map - Unit 4 Flashcards

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1
Q

Utilize the nursing process to construct an ___ ___ of __ for a patient based on a critical analysis of patient assessment data.

A

Individualized plan of care.

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2
Q

Nursing Process - def

A

systematic method of giving humanistic care that focuses on achieving outcomes in a cost-effective manner.

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3
Q

Scientific Method - personalized or not personalized?

A

Not personalized!

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4
Q

Intuitive method - direct understanding of the…

A

situation. Based on background of the situation - knowledge + skill.

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5
Q

Care Plans - Organized so nurse can quickly identity nursing actions to be delivered. T/F?

A

True!

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6
Q

5 Steps of the Nursing Process -

A 
Assessment.
Diagnosis.
Planning. 
Implementation. 
Evaluation.
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7
Q

Why do we do care plans?

A

Requirement set forth by National practice standars. (ANA, TJC.) Basis for NCLEX exams, etc.

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8
Q

Assessment - the first step in ___ a patient’s health status.

A

Determining.

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9
Q

We don’t need to report significant abnormalities immediately. T/F?

A

False - we must!

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10
Q

Data doesn’t need to be complete or accurate. T/F?

A

False - it must be!

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11
Q

Assessment - what are some of the things we do here?

A

Gather information (puzzle pieces).

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12
Q

What are the 5 activities needed to perform a systematic assessment?

A

Collect data, verify data, organize data, identify patterns, report & record data.

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13
Q

Data collection - begins before you actually see the patient. T/F?

A

True - like ER notes, chart reviews, etc.

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14
Q

What’s important data?

A

Name, age, gender, advanced directive, lab tests, meds, allergies, support services, emotional state, culture assessment, etc.

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15
Q

What is some of the stuff taken from a comprehensive physical assessment?

A

Vital signs, height/weight, review of systems, standardized risk assessments.

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16
Q

Should we cluster data into groups, according to nursing or medical models, like Maslow’s?

A

Yes!

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17
Q

When is the initial assessment done?

A

Shortly after admission.

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18
Q

What is a focused assessment?

A

When it’s trying to look at one specific problem.

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19
Q

Emergency Assessment - what is it?

A

When there is a crisis.

20
Q

What is a time-lapsed assessment?

A

Done to compare status to baseline data - could be done in LTC, etc.

21
Q

Diagnoss - what is it?

A

We take the assessment –> critical analysis –> and then diagnose.

22
Q

Nurses are responsible for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment. T/F?

A

True!

23
Q

Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved. T/F?

A

True!

24
Q

Diagnostic reasoning - apply critical thinking to problem identification. T/F?

A

True!

25
Q

What are some of the fundamental principles of Diagnostic reasoning?

A

Recognizes diagnosis, keeps an open mind, back up diagnosis with evidence, intuition, independent thinker, know your qualifications and limitations, etc.

26
Q

Nursing Diagnosis - actual problem with evidence. T/F?

A

True!

27
Q

With a nursing diagnosis, we use medical diagnosis. T/F?

A

FALSE. It is not a medical diagnosis.

28
Q

We can state 2 separate problems in one diagnosis. T/F?

A

False!

29
Q

Planning - what do we do here?

A

Set your priorities of care, what needs done first/last, etc. We have to identify goals and outcomes, etc.

30
Q

Outcomes - need to be time related. T/F?

A

True!

31
Q

Short term goal - what’s the timeframe?

A

Less than a week.

32
Q

Long term goal - what’s the timeframe?

A

More than a week!

33
Q

Affective goal - what is it?

A

Change in values, believes, etc. Like smoking!

34
Q

Cognitive Goal - what is it?

A

Increasing patient knowledge.

35
Q

Psychomotor goal - what is it?

A

Shows they can do something!

36
Q

Nursing interventions are actions performed by nurse to reach goal or outcome. T/F?

A

True!

37
Q

Direct Care Intervention - what is it?

A

Direct action performed to client (like inserting a foley catheter.)

38
Q

Indirect Care Intervention - what is it?

A

actions performed away from client (looking at lab results.)

39
Q

Physician Intervention - what is it?

A

An intervention done with an order/by doctor.

40
Q

Collaborative intervention - what is it?

A

An intervention where everyone is involved.

41
Q

What happens in implementation?

A

Putting your plan into action, set priorities after report, assess and reassess, perform interventions, etc.

42
Q

Protocols - def

A

written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation.

43
Q

Standing Orders - document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific conditions. T/F?

A

True!

44
Q

Implementation Process Involves what 3 things?

A

Reassessing the client, reviewing and revising the existing care plan, and organizing resources and care delivery (equipment, personnel, environment.)

45
Q

Evaluation - what happens here?

A

Evaluation of individual plan of care, which includes determining outcome achievement. It measures the client’s response to nursing actions and the client’s progress toward achieving goals!

46
Q

What is a concept map care plan?

A

Innovative approach to planning and organizing nursing care. Essentially a diagram of patient problems and interventions! Roots in education and psychology.

Nursing - 115 (35 decks)

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