Ch. 5: Nursing Process and Critical Thinking Flashcards
Nursing process
organizational framework for the practice of nursing, problem solving, six phases, ANA Nursing Scope and Standards of Practice
Six phases of the nursing process
Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, Evaluation
Types of data
Cue, subjective, objective
Collecting data is part of the
assessment process
Sources of data
primary and secondary sources
Methods of data collection
interview, physical exams
A nursing diagnosis/patient problem statement
is a type of health problem that can be identified by the nurse
Components of patient problem statement
patient’s presenting signs and symptoms
contributing, etiologic (causative), and related factors
defining characteristics
Patient problems
may be actual or potential
Other types of health problems
collaborative problems, medical diagnosis, differentiating medical and nursing diagnoses
Patient-centered goals
indicates the degree of wellness desired, expected, or possible for the patient to achieve
provides a description of the specific, measurable behavior the patient will exhibit in a given time frame
Planning
the nurse establishes priorities of care and nursing interventions are chosen that will best address the nursing diagnosis, information is communicated through care plan, the nurse decides what interventions will be effective
Priority Setting
nursing diagnoses are ranked in order of importance for the patient’s life and health, physiological needs come before safety and security, safety and security come before love and belonging needs, life- and health-threatening problems are ranked before other types of problems, actual problems may be ranked before risk problems, priorities change as the patient progresses in the hospitalization
Nursing Interventions
activities that promote the achievement of the desired patient outcome, classified as physician-prescribed or nurse-prescribed
Nursing interventions in manuals and textbooks are often broad, general statements,
it is necessary to convert these into more specific, instructional statements
Nursing interventions must be written to
reduce the likelihood of misinterpretation
Should include the
subject, action verb, and qualifying details
Establishing desired patient outcomes
the nurse predicts the condition of the patient following nursing interventions
This prediction is expressed in a statement that indicates the degree of wellness
desired, expected, or possible for the patient to achieve
Outcome:
a statement provides a description of the specific, measurable behavior that the patient will be able to exhibit in a given time frame following the intervention
Goal:
a statement about the purpose to which an effort is directed
Written nursing care plan is the product of
the nursing process
What is important to have in order to promote the continuity of patient care?
written guidelines
Linear care plan vs concept maps
common components in the educational setting, one of two types of care plans are noted in the educational setting
The NANDA-I has formed a relationship with two other groups
Nursing Intervention Classification (NIC) and Nursing Sensitive Outcome Classification (NOC)
Role of the practical/vocational nurse
provide direct bedside nursing care, the direct care plan helps the LPN/LVN to closely observe, prioritize, intervene, and evaluate the care provided to and for the patient
Managed care
a health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame
Case management
a certified nursing specialty; refers to the assignment of a health care provider to a patient so the care of that patient is overseen by one individual
Multidisciplinary plan
that schedules clinical intervention over an anticipated time frame for high-risk, high-volume, high-cost types of cases
A multidisciplinary plan includes elements such as
diagnostic tests, treatment, activities, medications, consultations, education, daily outcomes, and discharge planning
Variance
patient does not achieve the projected outcome
Critical thinkers
think with a purpose, they question information, conclusions, and points of view
are logical and fair in their thinking
Implementation
fifth phase of the nursing process, the nurse and other members of the team put the established plan into action to promote outcome achievement
Using evidence-based interventions
the plan is implemented in a timely and safe manner
Evidence-based practice
nursing research is the evidence based for this
What is a primary source of data?
The patient
What are the components of a nursing diagnosis?
Nursing diagnosis, title or lablel
Definition of the title or label
Contributing, etiologic, or related factors
Defining characteristics
A systematic method by which nurses plan and provide care for patients is known as
nursing process
Which type of nursing diagnosis is the following?
“Describes human responses to health conditions/life processes that may develop a vulnerable individual/family/community?
risk
A well-written patient-centered goal or desired patient outcome statement:
uses a measurable verb
is specific for the patient and the patient’s problem
is realistic for the patient and the patient’s problem
includes a time frame for the patient’s reevaluation
uses the word patient as the subject of the statement
