Ch 1 Flashcards
What are nurses in relation to healthcare
The backbone of healthcare
Why must a health history be complete and accurate
For decision making in an accurate nursing diagnosis
What is the American nurses association (ANA) and what does it promote? What does it give and guide
A professional nursing organization that promotes:
- optimal function
- wellness of body, mind, spirit
The American nurses association gives and guides nursing goals
What are the four broad nursing goals
-To promote health
(through teaching)
- to prevent illness and injury
(through teaching) - to treat human responses to health or illness
Holistically
-to advocate for individuals, families, communities, populations
Nurses aka guardians of health
What is known as advocating for underserved populations to decrease disparities
Known as promoting social justice
(ensuring equal treatment for all)
Define social justice
Ensuring equal treatment for all
What are 3 roles of nurses for protection
what three areas do they protect and take responsibility of
- Ethical (patient)
- Legal
- Safety
List the legal responsibilities a nurse must protect from
- Assault (threat)
- Battery (laying hands)
- Defamation
- Negligence
- Malpractice
- Breach of confidentiality (HIPPA)
 -False imprisonment (restraining for convenience)
What does a scope and standards of practice and code of ethics for nurses address
It addresses nursing values “behavior”

Give the nursing values in the code of ethics and briefly describe
(5)
Altruism
: concerned for welfare of othersHuman dignity
: showing respect ensuring privacy and confidenceAutonomy
: right to make decisionsIntegrity
: always providing honest infoSocial justice
: equal treatment for all
Define altruism as a nursing value
Concern for welfare of others
Define human dignity as a nursing value
Showing respect and ensuring privacy and confidence
Define autonomy as a nursing value
The right to make decisions
Define integrity as a nursing value
Always providing honest information
Define social justice as a nursing value
Equal treatment for all
Give the different types of nursing interventions (4) and a description of each
- Dependent nursing interventions
- requires doctors orders
- Independent nursing interventions
-done alone
• teachings, vitals, monitoring - Collaborative interventions
- help from others
• ambulating , turning
- help from others
- Inter-dependent interventions
- progression of treatment
• clear to bland diet
- progression of treatment
What are care responsibilities of a nurse for a patient
Patient teachings, therapeutic communication, and physical procedures
Define what it means to be a member of the profession
To be a lifelong learner and continuing education
Being an advocate for your patient and profession and upholding values ( altruism, human dignity, autonomy, integrity, social justice)
Who is considered a professional nurse
A nurse with a bachelors in the science of nursing
What are unique things that advanced practice nurse may do within their scope of practice for patients
Advanced practice registered nurses may prescribe and write orders some can even work independently
Give the verbatim definition of health assessment
Gathering information about the health status of the patient, analyzing and synthesizing those data, making judgments about nursing interventions based on the findings and evaluating patient care outcomes
What is complete and accurate data in relation to patient outcomes
Complete and accurate data = accurate diagnosis= Wanted outcomes
Give the two components of health assessment (equation)
Health assessment = health history (interview) + physical assessment
What are other components of a health assessment that are not commonly described
Psychological, socio cultural, spiritual, economic, lifestyle
How does the nursing process begin
With a complete and accurate health assessment
What is wellness oriented towards
Maximizing the potential function of ADL
Define Healthy People*
A National model for health promotion, risk reduction that aims to increase length and quality of life and eliminating Health disparities
How often are healthy people goals reevaluated and revised
Every 10 years
Give the healthy people 20 2010 goals
Physical activity Overweight/obesity Tobacco use Substance abuse Responsible sexual behavior Mental health Injury and violence Environmental quality Immunization Access to healthcare
What are outcomes associated with in the nursing process
Outcomes are associated with teachings
What is primary prevention And examples
Primary prevention is preventing and educating
- immunizations
- Health teachings
- Safety
What is secondary prevention and examples
SS secondary = screenings for early diagnosis and treatment
- mammo/ Pap smears/ colonoscopy
- vision/hearing/scoliosis
- TB
What is tertiary prevention and examples
Tertiary is preventing complications of disease and promoting highest level of health
- diet teachings
- Exercise
- Administration of pain medications*
ADPIE: A
Give all related info
Assessment: collect data
S: says ( subjective)
O: observe (Objective
Prioritize ABC/CAB Maslow‘s Acute v chronic Actual (now) v potential (risk)
P-roblem
E- tology (R/T)
S- S&s (AEB)
ADPIE: D
Give all related info
Diagnosis : data clustering
NANDA
P-roblem
E- tology (R/T) >actual
S- S&s (AEB)
E- tology (R/T) > potential
S- S&s (AEB)
ADPIE: P
Give all related info
PLANNING
Long term/ short term
S- pacific M-easurable (#) A- attainable R- esult oriented T- ime framed (time and date)
ADPIE: I
Implementation/intervention: treatment
Collaborative
-dependent
-independent
ADPIE: E
Evaluation
Met/ unmet/ partially met
After evaluation go back to planning
Define ADPIE (book definition)
A scientistic systematic problem solving approach
Is ADPIE linear
No, it’s overlaps
Define critical thinking
Critical thinking= clinical reasoning/ clinical judgement
: that ability to understand and act on what you know about the nursing content
Define diagnostic reasoning
Proposing a diagnosis
Gathering and clustering data to draw interference and propose diagnosis
Give the 7 step process of diagnostic reasoning
- id ab/norm +strengths and weaknesses
- Cluster data
- draw inferences
- propose nursing diagnosis
- check for defining characteristics
- Confirm and rule out nursing diagnosis
- Document
Describe and Give requirements for emergency assessment
Is there anything done simultaneously?
What is it based on?
Done in life-threatening and unstable situations
- perform intervention simultaneously in emergency assessment
Based on A, B, C, D, E
give meanings of ABCDE
A-irway (protects C spine)
B- reathing (rate/ depth)
C- irculation (rate/ rhythm, color)
D - isability (loc)
E - exposure
Describe and Give requirements for comprehensive assessment
When is A comprehensive Assessment usually done in the hospital and long term care facility
Comprehensive = head to toe
A complete health history and physical assessment
During admission In hospitals in long-term care settings
Describe and Give requirements for focused assessment
FOCUSED = SPECIFIC
A focused assessment is smaller in scope but assess body systems SPECIFIC to signs and symptoms
What is the most important skill in nursing based on critical thinking and clinical reasoning
Priority setting
What situation is of the upmost priority and what do you use to prioritize pt care during the situation
Life-threatening situations are top priority, look at what will save lives
Based on ABC DE & CAB
What is acuity, what is high acuity and what is low acuity
Acuity is level of severity of illness
High acuity is very severe
Low acuity is moderately severe
What determines the frequency of assessment
Mainly pt need but it varies based on the standard of care by the facility (how often they choose)
How often do you do a comprehensive assessment in a long-term care facility (I.e. nursing home) v icu
Once a month
V
Q shift
How often do you do it focused assessment post treatment
About 30 minutes after meds
When are times in life when will visit assessments are most frequently done
(2 answers)
Birth -10: for g&d
65+: for treatment of illnesses
Why is it important to know normal development V delayed development
To identify if development is appropriate for age
What are cultural considerations for those of the same culture
Traits that a group of people share where they learn how to be healthy and how to be ill
I.E: Hispanics have home remedies when ill
What is cultural competence
Cultural competence is having cultural sensitivity considering the total context of a patient situation across cultural boundaries
How do I use cultural competence in healthcare to deliver care
We assess how their culture affects the care we can give and the patient’s health as well as treating the patient to what they practice
What is Stereotyping and how do you avoid it?
Stereotyping is assuming of cultures and to avoid it you should ask your patient directly what their culture is and what they practice
When giving a Health Assessment with another person in the room what should you as a nurse do to maintain confidentiality
Obtain patient permission for others to be present by asking “ is it OK for them to be here for the assessment”
During a health assessment who do you get subjective data from and what is it used to to build between the pt and the nurse
How do you document subjective data
You get subjective data from the patient (primary source) and it’s used to build rapport and a relationship
Use quotation marks
Give an example of objective data
Vital signs, anything observable visually
When documenting what are DONTS
When documenting what are DOs
Don’t use white out
Don’t erase
Do correct mistakes by drawing 1 line and putting initials
When documenting using SBAR what does it stand for
Situation (why)
Background (circumstance)
Assessment (subj/obj)
Recommendation suggestion
Name the three major frameworks for health assessment
- functional assessment
- ADL and functional patterns
- head to toe assessment
- comprehensive
- most organized*
3.body systems approach
- promotes critical thinking
-clusters similar data together

What does evidence-based Practice rely on
Research findings and scientific support
