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Roy Adaptation > Chapter 3 - Nursing Process according to RAM > Flashcards

Chapter 3 - Nursing Process according to RAM Flashcards

1
Q

ANA stands for what?

A

American Nurses Association

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2
Q

Who are the recipients of nursing care?

A

people as individuals and as collective such as families, groups, society, etc.

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3
Q

______ ______ is the problem-solving approach of gathering data, identifying capacities and needs of a patient, est. goals, selecting and implementing approaches for nursing care and evaluation of the outcomes of care provided.

A

Nursing Process

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4
Q

In the RAM nursing process, there are two parts being assessed. What are they?

A
  1. Behavior

2. Stimuli

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5
Q

T or F: RNs must start an individualized plan for each patient after a thorough assessment.

A

True. You cannot checklist a patient. THe RN must gather data, assess the data and create an individual plan.

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6
Q

5 steps of ANA Std Practice Nursing Process:

A
  1. Assessment - collect data
  2. Diagnosis (clinical judgment - not the same as med diag)
  3. Goal setting and Interventions (what skills are lacking that need addressing)
  4. Implementation
  5. Evaluation (was the plan effective?)
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7
Q

T or F: ANA standards of practice allows you to choose which portions of data to collect.

A

False. You must assess every part. You cannot write N/A. You cannot skip checking the eye sight because you do not enjoy it. You must chart all of it!

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8
Q

Why are goals important for the patient?

A

Gives patient something to work toward in order to be discharged.

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9
Q

Can CNA and LVN collect data and implement care?

A

Yes. They cannot assess patients, diagnose, set goals or evaluate patients.

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10
Q

Is it acceptable for an RN to take report from another nurse and go on about his or her day?

A

No. The RN should still assess the person. Check to see if conditions have changed since the nurse handing over last checked. Check to see if previous nurse missed anything.

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11
Q

What are the six steps identified in the nursing process according to the RAM:

Memorization tip:
BSDGIE (Bed Sounds Darn Good, I’m Exhausted)

A
  1. 1st level assessment of behavior/response
  2. 2nd level assessment of stimuli
  3. Nursing Diagnosis (clinical judgment)
  4. Goal setting (plan of action/desired behavioral outcome relative to identified problem)
  5. Intervention (Implementation/promote adaptation/help patient reach goals set)
  6. Evaluation (was the plan effective? if not, reassess)
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12
Q

What is the difference between RAM and ANA nursing process?

A

Roy’s assessment has two levels of assessment upfront: level 1 - response (behavior) and level 2 - stimuli

ANA Std requires collection of data upfront.

Both have Diagnose, Goal/Plan, Intervention/Implementation, evaluation

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13
Q

What are the three types of assessment?

A
  1. Nursing - biopsychosocialspiritual data
  2. Focused - problem focused
  3. Physical - head to toe assessment including body systems
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14
Q

What are sources of data we can collect from re:patient?

A

History from patient and/or family, medical records, other health care workers, observation, measurements (exam)

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15
Q

If a family member shares information with you, are you in violation of HIPAA?

A

No. If you give information about the patient back to the family, you may be violating hipaa.

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16
Q

What skills are used in assessment?

A

Communication, Inspection/observation, auscultation, palpation, measurement (temp), review of records.

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17
Q

T or F: Observable behaviors cannot be seen, heard or measured. They must be reported by the patient.

A

False. Nonobservable behaviors fit this definition. Observable are able to be seen, heard and measured.

18
Q

Indicators of effective adaptation include the use of normal values (standards). When there is cognator ineffectiveness, Roy says we can look for the following signs:

A
  1. BP increase
  2. tension
  3. excitement
  4. loss of appetite
  5. increase cortisol
19
Q

What are indicators of cognator ineffectiveness (failure to adapt):

A
  1. Faulty perception/infor processing
  2. Ineffective learning
  3. Poor judgment
  4. Inappropriate affect (you tell someone their mom died and they laugh or tell you they wants a candy bar)
20
Q

What happens during the first level assessment?

A

Assess behaviors. Compare responses to specific criteria. See, hear and measure. Use all senses to assess patient.

21
Q

Review Erikson’s 8 PSYCHO-SOCIAL stages of development (NCLEX)

A

http://www.youtube.com/watch?v=PC2G5oFliyk

22
Q

Culture, Family, Developmental Stages, Integrity of adaptive modes, adaptation level, cognator-innovator effectiveness, environment are all considered to be what?

A

Common Stimuli

23
Q

What takes place during RAM 2nd level assessment?

A

Check stimuli.

  • Review environmental factors that contribute to the behavior observed in 1st level assessment.
  • Identify focal, contextual and residual stimuli.
  • determine negative stimuli causing adaptation problems.
24
Q

What does NANDA stand for?

A

North American Nursing Diagnosis Association

25
Q

THis step is derived from Level 1 and 2 assessment and it gives a statement which describes a person’s actual or potential adaptation problem/state.

A

Step 3 nursing diagnosis

26
Q

What is a name for nursing diagnosis?

A

NANDA - a clinical judgment to actual or potential health problems.

27
Q

T or F: NANDA must be derived from textbook evidence as to why intervention works.

A

True

28
Q

What are the two types of nursing diagnosis (NANDA)?

A
  1. Actual - issue is present and valid
  2. Risk (potential problem) - issue not present BUT negative stimuli are present (ex wandering in an elderly person…dementia?)
29
Q

If the NANDA is an ACTUAL diagnosis, it is a 3-part statement. What are the three parts?

Hint: LSB

A
  1. NANDA Label - (Ex. Depression)
  2. Stimuli - (Ex. Failure in school - Focus)
  3. Behaviors - (Ex. Crying)
30
Q

If the NANDA is a RISK diagnosis, it is a 2-part statement. What are the three parts?

A
  1. NANDA Label - (ex. Anxiety)

2. Stimuli - (ex. Test)

31
Q

Questions to ask when making a nursing diganosis…

A
  1. Are there adqequate clustered ineffective responses and related caustative?
  2. Is there a logical relationship between behaviors and stimuli?
  3. Is diagnosis truly nursing diag (and not medical diag.)?
32
Q

Step 4 of RAM model nursing process is ______ ________ .

A

Goal Setting

33
Q

T or F: The goals set do not include patient input.

A

False. Patient must collaborate or will not be successful.

34
Q

What is a goal?

A

A clear statement of the behavior outcomes of nursing care/nursing diagnosis. What we want to happen, what we are working toward.

35
Q

What does goal setting focus on?

A

Measured changes in observed behaviors.

36
Q

What is criteria for goal?

A
  1. Who is the goal for? Patient, family, etc
  2. What is the goal? lose weight, take a bath, walk
  3. Must have time frame
  4. Must be measurable!!
37
Q

What is step 5 of Nursing Process?

A

Intervention

38
Q

This step of the nursing process involves manipulating stimuli and activities the nurse identities to carry out in order to achieve the goals.

A

Intervention

39
Q

Nursing interventions can be _____, ___________, or ________.

A
  1. Independent
  2. Interdependent (diet and exercise)
  3. Dependent
40
Q

This is the sixth step in the nursing process. It involves judging the effectiveness of nursing interventions in relation so the person’s behavior. Did it work? Do we need to change?

A

Evaluation (of plan –> to goal–>outcome)

41
Q

There are three evaluation outcomes:

A
  1. Goal achieved
  2. Goal partially achieved
  3. Goal not achieved
42
Q

When the goal is not achieved, reassessment is needed. What questions do we ask ourselves?

A
  1. Is diagnosis correct?
  2. Has the goal been mutually set?
  3. Is more time needed?
  4. Should we change the goal?
  5. Should intervention be changed?

Roy Adaptation (8 decks)

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