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Foundations - Exam #2 > Chapter 9 (Nursing Process) Vocab > Flashcards

Chapter 9 (Nursing Process) Vocab Flashcards

1
Q

Assessment

A

the thorough, systematic, and deliberate collection of patient data

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2
Q

Health History

A

Is comprehensive and includes info about the patients physical and developmental status, emotional health, social practices, goals, values, lifestyle, expectations about health care system

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3
Q

Cue

A

information that you obtain through use of your senses

Anything a patient says and what you observe

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4
Q

Inference

A

your judgement or interpretation of cues

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5
Q

Two steps of the nursing process

A
  1. Collection and verification of data from primary sources and secondary sources
  2. Analysis of the data
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6
Q

Two Types of Data

A

Subjective and Objective

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7
Q

Subjective Data

A
  • Patients’ verbal descriptions of their health problems

* Examples: Feelings of fear, anxiety, physical discomfort, mental stress

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8
Q

Objective Data

A
  • Observations or measurements of a patient’s health status

* Inspection of a wound, observations made about gait

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9
Q

Open-Ended Questions

A

Questions that prompt patients to describe a situation in more than one or two words; not yes/no questions

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10
Q

Back-channeling

A

The practice of giving positive comments such as “all right,” “go on,” or “uh-huh,” to the speaker.

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11
Q

Closed-Ended Questions

A

Questions that limit answers to one or two words such as yes/no, a number, or a the frequency of a symptom

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12
Q

Validation

A

(of assessment data) is the comparison of data with another source to confirm the data accuracy

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13
Q

Phases of an Interview

A

Orientation Phase
Working Phase
Termination Phase

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14
Q

Sources of Data

A 
Patient
Family & Significant Other
Health Care Team
Medical Records
Other Records and Scientific Literature 
Nurse Experience
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15
Q

Final Step of Assessment

A

Communicate the information and document the information

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16
Q

Nursing Diagnosis

A

a clinical judgment about the patient in response to an actual or potential health problem

Provides the basis for selection of nursing interventions

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17
Q

Medical Diagnosis

A

The identification of disease condition based on specific evaluation of physical signs, symptoms, history, and diagnostic tests and procedures

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18
Q

Collaborative Problem

A

Actual or potential physiological complication that nurses monitor to detect a change in patient status

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19
Q

Nursing Diagnostic Process

A

a process that requires the use of critical thinking to analyze and interpret assessment data to form a nursing diagnosis

includes data clustering, interpreting and analyzing, identifying patient needs, and formulating the nursing diagnosis or collaborative problem

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20
Q

Data Cluster

A

a set of signs or symptom gathered during assessment that you group together in a logical way

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21
Q 
Data Analysis 
(and interpretation)
A

involves recognizing patterns in clustered data, comparing them with standards, and coming to a conclusion about the patients response to a health problem

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22
Q

NANDA International (NANDA-I) and nursing diagnosis

A

North American Nurse Diagnosis Association

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23
Q

NANDA International and nursing diagnosis

A

Group that developed a model for organizing nursing diagnosis for documentation, auditing, and communication purposes

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24
Q

Defining Characteristics

A

Observable cues and inferences (clinical criteria or assessment findings) that support an actual nursing diagnosis

The cues that cluster as manifestations of a problem-focused or health promotion diagnosis or syndrome

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25
Q

Three types of nursing diagnoses

A

Problem Focused
Risk
Health Promotion

26
Q

Problem Focused Nursing Diagnosis

A

Clinical judgment concerning an undesirable human response to a health condition or life process that exists in an individual, family, group, or community

These diagnosis have sufficient assessment data to support them

27
Q

Risk Nursing Diagnosis

A

Clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to a health condition or life process

28
Q

Health Promotion Nursing Diagnosis

A

Clinical judgment concerning motivation and desire to increase well-being and actualize human health potential

Supported by defining characteristics

29
Q

Risk Factors

that influence risk nursing diagnosis

A

the environmental, physiological, psychosocial, genetic, and chemical elements that place a person at risk for a health problem

30
Q

Components of a nursing diagnosis

A

Diagnostic Label
Related Factor
Definition
the PES Format

31
Q

Related Factor

A

What explains why you chose the diagnostic label; it is associated with a patient’s actual or potential response to the health problem and can change by using specific nursing interventions

32
Q

Four Categories of Related Factors

A

pathophysiological (some sort of biological or psychological factor), treatment-related (treatment has weakened the patient), situational (environmental or personal), and maturational (things that happen as we mature)

33
Q

Etiology***

A

is always within the domain of nursing practice and a condition that responds to nursing interventions

34
Q

What is the PES format and what does it stand for?

A

The three part nursing diagnostic label

P (problem), E (Etiology or related factors), S (symptoms or defining characteristics)

35
Q

Concept Map***

A

A graphical way of organizing and linking data about a patient’s multiple diagnoses

It helps you critically think about your patient’s nursing diagnoses, their relationship to one another, and their effect on the nursing care plan

36
Q

Sources of Diagnostic Erros

A

Data Collection, interpretation and analysis, data clustering, and the diagnostic statement

37
Q

Planning

A

the 3rd step in the nursing process that involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions

38
Q

Goal (patient centered)

A

a broad statement that described a desired change in a patient’s condition or behavior

it is realistic and can be short term or long term

39
Q

Expected Outcomes

A

The measurable change in the patient that’s used to evaluate goal achievement

40
Q

Nursing-Sensitive Outcome

A

a measurable patient or family state, behavior, or perception largely influenced by and sensitive to nursing interventions

Ex: reduction of pain severity, incidence of pressure injuries, and incidence of falls

41
Q

SMART Goals/Expectations

A

Specific, Measurable, Attainable, Realistic, Timed

42
Q

Scientific Rationale

A

The reason for the intervention

43
Q

Independent Nursing Interventions

A

“Nurse Initiated” - the actions that a nurse initiates

Ex: raising head of bed while eating, giving a bath, explaining the side effects of a med

44
Q

Dependent Nursing Interventions

A

“Health Care Provider-Initiated” – Actions that require an order from a health care professional

Ex: giving a medication, preparing patient for diagnostic testing

45
Q

Collaborative Interventions

A

“Interdependent Nursing Interventions” —Therapies that required the combined knowledge, skill, and expertise of multiple health care professionals

Ex: Recommendations from the dietician or therapist

46
Q

Nursing Care Plan

A

includes nursing diagnoses, goals and expected outcomes, and individualized nursing interventions.

47
Q

Interdisciplinary care plan

A

Contributions from all disciplines involved in patient care

48
Q

Consultation

A

the process by which you seek the expertise of a specialist, such as your nursing instructor or clinical nurse specialist, to identify ways to handle problems in patient management or in planning and implementation of therapies

49
Q

Implementation

A

The performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care

50
Q

Nursing Intervention

A

is any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes

51
Q

Direct Care Interventions

A

treatments performed through interactions with patients

Ex: med administration, insertion of IV catheter or counseling during times of grief

52
Q

Indirect Care Interventions

A

treatments performed away from but on behalf of the patient or groups of patients

Ex: managing the patient’s environment, documentation, interdisciplinary collaboration

53
Q

Clinical Practice Guideline

A

or protocol - is a systematically developed set of statements (policies and procedures)

54
Q

Care Bundle

A

a group of interventions when executed together result in better patient outcomes than when implemented individually

ex: sepsis management, prevention of ventilator-associated pneumonia

55
Q

Standing Orders

A

Pre-printed document that contains orders for conducting routine therapies, monitoring guidelines, and diagnostic procedures for specific patients with identified clinical problems

56
Q

Nursing Implementation Skills

A

Cognitive, interpersonal, psychomotor

57
Q

Activities of Daily Living (ADLs)

A

Activities performed during the course of a day

ex: ambulation, eating, dressing, grooming

58
Q

Instrumental Activities of Daily Living (IADLs)

A

more in-depth activities performed

Ex: shopping, meal prep, handling finances, etc

59
Q

Counseling

A

Method that helps patients use a problem-solving process to recognize and manage stress and facilitate interpersonal relationships

60
Q

Evaluation

A

the crucial step of determining whether a patient’s condition or well-being improved after an intervention was delivered

61
Q

5 Elements of Evaluation Process

A

1) comparing achieved effect with goals and outcomes
2) Collecting data to determine if your patient met the criteria or standards
3) interpreting and summarizing findings
4) recognizing errors or unmet outcomes
5) revising the care plan as needed

Foundations - Exam #2 (5 decks)

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