Care Plan/Concept Map - Unit 4 Flashcards
Utilize the nursing process to construct an ___ ___ of __ for a patient based on a critical analysis of patient assessment data.
Individualized plan of care.
Nursing Process - def
systematic method of giving humanistic care that focuses on achieving outcomes in a cost-effective manner.
Scientific Method - personalized or not personalized?
Not personalized!
Intuitive method - direct understanding of the…
situation. Based on background of the situation - knowledge + skill.
Care Plans - Organized so nurse can quickly identity nursing actions to be delivered. T/F?
True!
5 Steps of the Nursing Process -
Assessment. Diagnosis. Planning. Implementation. Evaluation.
Why do we do care plans?
Requirement set forth by National practice standars. (ANA, TJC.) Basis for NCLEX exams, etc.
Assessment - the first step in ___ a patient’s health status.
Determining.
We don’t need to report significant abnormalities immediately. T/F?
False - we must!
Data doesn’t need to be complete or accurate. T/F?
False - it must be!
Assessment - what are some of the things we do here?
Gather information (puzzle pieces).
What are the 5 activities needed to perform a systematic assessment?
Collect data, verify data, organize data, identify patterns, report & record data.
Data collection - begins before you actually see the patient. T/F?
True - like ER notes, chart reviews, etc.
What’s important data?
Name, age, gender, advanced directive, lab tests, meds, allergies, support services, emotional state, culture assessment, etc.
What is some of the stuff taken from a comprehensive physical assessment?
Vital signs, height/weight, review of systems, standardized risk assessments.
Should we cluster data into groups, according to nursing or medical models, like Maslow’s?
Yes!
When is the initial assessment done?
Shortly after admission.
What is a focused assessment?
When it’s trying to look at one specific problem.
Emergency Assessment - what is it?
When there is a crisis.
What is a time-lapsed assessment?
Done to compare status to baseline data - could be done in LTC, etc.
Diagnoss - what is it?
We take the assessment –> critical analysis –> and then diagnose.
Nurses are responsible for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment. T/F?
True!
Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved. T/F?
True!
Diagnostic reasoning - apply critical thinking to problem identification. T/F?
True!
What are some of the fundamental principles of Diagnostic reasoning?
Recognizes diagnosis, keeps an open mind, back up diagnosis with evidence, intuition, independent thinker, know your qualifications and limitations, etc.
Nursing Diagnosis - actual problem with evidence. T/F?
True!
With a nursing diagnosis, we use medical diagnosis. T/F?
FALSE. It is not a medical diagnosis.
We can state 2 separate problems in one diagnosis. T/F?
False!
Planning - what do we do here?
Set your priorities of care, what needs done first/last, etc. We have to identify goals and outcomes, etc.
Outcomes - need to be time related. T/F?
True!
Short term goal - what’s the timeframe?
Less than a week.
Long term goal - what’s the timeframe?
More than a week!
Affective goal - what is it?
Change in values, believes, etc. Like smoking!
Cognitive Goal - what is it?
Increasing patient knowledge.
Psychomotor goal - what is it?
Shows they can do something!
Nursing interventions are actions performed by nurse to reach goal or outcome. T/F?
True!
Direct Care Intervention - what is it?
Direct action performed to client (like inserting a foley catheter.)
Indirect Care Intervention - what is it?
actions performed away from client (looking at lab results.)
Physician Intervention - what is it?
An intervention done with an order/by doctor.
Collaborative intervention - what is it?
An intervention where everyone is involved.
What happens in implementation?
Putting your plan into action, set priorities after report, assess and reassess, perform interventions, etc.
Protocols - def
written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation.
Standing Orders - document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific conditions. T/F?
True!
Implementation Process Involves what 3 things?
Reassessing the client, reviewing and revising the existing care plan, and organizing resources and care delivery (equipment, personnel, environment.)
Evaluation - what happens here?
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!
What is a concept map care plan?
Innovative approach to planning and organizing nursing care. Essentially a diagram of patient problems and interventions! Roots in education and psychology.
