Chapters 14 & 16 Flashcards
describes the responses to health conditions or life processes that exist in an individual, family or community
Actual Nursing Diagnosis
the collection of data pertinent to the patient’s health status or situation
Assessment
a condition or ethology identified from the patient’s assessment data. It is associated with the patient’s actual or potential response to the health problem and can be changed through the use of nursing interventions.
Related Factor
objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion
Clinical Criteria
patients’ verbal descriptions of their health concerns
Subjective Data
describes levels of wellness in an individual, family, or community that can be enhanced. A clinical judgement. Transition from a specific level to a higher level
Wellness Nursing Diagnosis
systematic methods for collecting data on all body systems
Review of Systems
describes human response to health conditions or life processes that will possibly develop into a vulnerable individual, family or community
Risk Nursing Diagnosis
an objective behaviour or response that a patient is expected to achieve in a short time, usually less than a week
Short Term Goal
level of quality or attainment
Standards
can be answered stating yes or no
Closed-Ended Questions
an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status
Collaborative Problem
a visual representation that show the connection between a patient’s health problems
Concept Map
involves seeking the expertise of a specialist, such as a nurse educator, registered nurse, or a clinical nurse specialist, to identify ways of approaching and managing the planning and implementation of therapies
Consultation
inter professional treatment plans that outline the treatments or interventions that patients may require for treatment of a condition
Critical Pathways
information that a nurse obtains through use of the senses (e.g. crying)
Cue
another name for a condition
Etiology
the identification of the nature of an illness or other problem by examination of the symptoms
Diagnosis
describes the essence of a patient’s response to health conditions in as few words as possible
Diagnostic Label
assessing the patient’s response to the selected intervention to determine whether the intervention was effective
Evaluation
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then establishing a reasoned conclusion about the patient’s responses to a health problem
Data Analysis
an organized collection of structured information, or data, typically stored electronically in a computer system
Database
the clinical criteria or assessment findings that help confirm an actual nursing diagnosis
Defining Characteristics
specific patient behaviours or physiological responses that nurses set to achieve through nursing diagnosis or collaborative problem resolution
Expected Outcomes
also known as expected outcomes
Goals
care and support plans are developed with the person
Person-Centred Plan of Care
a clinical judgement of a person’s, family’s or community’s motivation and desire to increase well-being and actualize human health potential, as expressed in their readiness to enhance specific health behaviours, such as those related to nutrition and exercise
Health Promotion Nursing Diagnosis
carrying out a plan
Implementation
a specific and measurable behavioural response that reflects a patient’s highest possible level of wellness and independence in function
Person-Centred Goal
involves the creation of a formal plan that prescribes strategies and alternatives attain the expected outcomes
Planning
the ranking of nursing diagnoses or patient problems, using principles such as urgency or importance, to establish a preferential order for nursing action
Priority Setting
ones judgement or interpretation of a cue (e.g. crying means they are sad or afraid)
Interview - organized conversation with the patient
Inference
card-filing system that allows quick reference to the needs of the patient for certain aspects of nursing care
Kardex
objective behaviour or response that a patient is expected to achieve over a longer period, usually over several days, weeks or months
Long-Term Goal
the identification of a disease, condition on the basis of specific evaluation of physical signs, symptoms, the patient’s medical history, and the results of diagnostic test and procedures
Medical Daignosis
an approved nursing diagnosis
NANDA International
a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing
Nursing Diagnosis
a detailed database the allows them to plan and carry out nursing care to meet patients’ needs
Nursing Health History
a cognitive framework through which the nurse aims to identify, diagnose, and treat actual and potential health issues and challenges of patients from a holistic perspective
Nursing Process
observations or measurements of a patient’s health status
Objective Data
help to determine the patient’s priorities and primary concerns, which can sometimes be different from what the nurse initially thinks the concern
Open-Ended Question
the comparison of data with another source to determine data accuracy
Validation
Which indication is served by setting a time frame for outcomes of care?
When the patient is expected to respond in the desired manner
Diagnostic label and Related factors make up a
Nursing diagnosis
Which topic would a nursing health history interview ideally focus on?
The patient
Which type of nursing diagnosis has the nurse given to a patient who ice diagnosed with urinary stress incontinence?
Actual diagnosis
Which basic concept would a nursing care plan emphasize?
Nursing diagnosis
Goals and expected outcomes
Specific nursing interventions
What is a measurable criterion used to evaluate goal achievement?
Expected outcome
The following categories are examples of:
Environmental
Physiological
Genetic
Chemical elements
Risk factors
Which type of question is used when starting the assessment of a patient?
Open-ended
The following is:
Review assessment data
Cluster clinical criteria that form a pattern
Choose a diagnostic label
Consider the context of a patient’s health problems and select a related factor
The correct order for a new patient admitted to the nursing unit
A benefit of an accurate nursing diagnosis
It helps ensure effective and efficient nursing interventions
Which statement describes a health promotion diagnosis, according to the North American Nursing Diagnosis Association International (NANDA)?
It indicates a person’s readiness to enhance specific health behaviours for well-being
During which process is the nurse avoiding an error when comparing the defining characteristics for acute pain with those for chronic pain and in the end selecting acute pain as the correct diagnosis?
Data interpretation
Which item would the nurse focus on when formulating a nursing diagnosis?
Potential response to a health problem
Which time does implementation begin as the fourth step of the nursing process?
After the care plan has been developed
The following patient-related data is considered _________ __________?
Age
Sex
Place of birth
identifying information
Setting the stage
Gathers information about chief concern, or problems - sets an agenda
Assessment / health history
Termination
Stages of a patient-centred interview in order
Which item describes a possible result of an incorrect nursing diagnosis?
Undesirable outcomes with patient care
The following are examples of:
Missing data
Inaccurate data
Disorganization
Lack of knowledge or skill
Factors cause errors in data collection
Interpretation a nurse would make about a patient who is scheduled for a cholecystectomy and is restless, has poor eye contact when speaking, and is asking a namer of questions?
The patient is anxious
These are examples of information that is found in the ___________________:
Age
Marital status
Address
Occupation
Working status
Source of healthcare
Types of insurance
Biographical information
What kind of report would be used to communicate between the critical care unit and the cardiac unit when a patient is moved?
Transfer report
Which explanation represents the meaning of SBAR?
Situation, background, assessment and recommendation
E.g. reposition the patient on right side. Encourage patient to use patient-controlled analgesia (PCA) device
This is a good example of:
P statement using the SOAP format
What type of interdisciplinary communication may take place when the primary health care provider would like an orthopedist to assess a patient’s complex fracture?
Consultation
Which Canadian law is violated when the nurse faxes a patient’s medical record to an unknown number?
Personal Information Protection and Electronic Documents Act (PIPEDA)
Which method will the nurse use to dispose of printed patient information?
Place in a secure canister for shredding
Which type of report would include the patient’s condition, anticipated condition, medications, and nursing interventions fulfilled so the next nurse on shift can follow the correct treatment and care for the patient?
Change-of-shift report
Which mode is used for the routine exchange of info among the members of the healthcare team?
Written reports
Oral communication
Which information does the nurse access in order to contact a patient’s guardian and update them about the patient’s health status?
Admission sheet
Which item warns a healthcare provider when prescribing medications using an EHR that the patient is allergic to prescribed medication and requires a change?
Clinical decision support system (CDSS)
Which classification is present when the nurse preforms a postoperative examination of a patient after left knee replacement surgery and finds the patient is experiencing a low-grade temperature, but the critical pathway on the patient unit indicates that the patient should be afebrile, normotensive, and eugenic after knee replacement surgery?
Variance
The following are examples that describe the purpose of ____________:
Helps in identifying trends in systems an unit operations that justify change
Helps quality improvement programs
Helps to identify need to change a procedure or policy
An incident report
Which type of record system allows the nurse to access patient’s medial record and review the education that other nurses provided to the patient during and initial hospitalization and three subsequent clinical visits?
Electronic health record
Which statement indicates a nurse understands the major advantage of using computerized provider order entry (CPOE)?
CPOE reduces transcription errors
Which response would the nurse make when a patient asks for a copy of their medical record?
Indicate that the patient has the right to read their record
Information the nurse should include while giving a change-of-shift report to another nurse who will be caring for a patient the next shift:
Patient’s name
Age
Diagnosis
Allergies
In a _______________ setting, the usual forms you would see on the patient’s chart are:
Assessment forms
Referral source information
Discipline-specific care plans
Physician’s plan of treatment
Professional order form
Medication administration record
Clinical progress notes
Discharge summary
Homecare
The following are examples of:
Documenting deviations from established norms
Shorthand method of documenting
Focuses on significant findings, assumes all standards are met unless they are documented
Patient concerns (narrative format)
Subjective assessment
SOAP
DAR
Outcomes of charting by exception (CBE)
Enter only _________ and factual information about the patient
Objective
Used to determine the hours of care and the number of staff required for any given group of patients every shift or every 24 hrs
Acuity ratings
Incorporates interdisciplinary approach to documenting patient care
Case management
Information about the assigned patients shared with nurses working on the next shift - can be written summary, or oral at a patient’s bedside.
Change-of-shift report
Patient meets all standards unless otherwise documented
Charting by exception (CBE)
Computerized program used within healthcare settings to aid and support clinical decision making
Clinical decision support system (CDSS)
one professional caregiver gives formal advice about the care of a patient to another caregiver
Consultations
a computer-based system that is meant to gather, store, and alter clinical data on patients
Clinical information system (CIS)
allows health care providers to directly enter order for patient care into the hospital information system
Computerized provider order entry (CPOE)
inter professional care plans that integrate best evidence for the treatment of a condition along a detailed pathway, with expected outcomes noted within an established time frame
Critical pathways
DAR notes
Data, action, response
the process of documenting nursing information about nursing care in health records
Documentation
a digital version of patient data that is found in traditional paper records
Electronic health record (EHR)
longitudinal (lifetime) record of all health care encounters for an individual patient. Legal record.
Electronic medical record (EMR)
a combination of hardware and software that protects private. Network resources from outside hackers, network damage, and theft or misuse of information
Firewall
a one- or two-page form that gathers all the important data regarding a patient’s condition
Flow sheets
a transdisciplinary study of the data flow and processing into more abstract forms such as information, knowledge, and wisdom along with the associated systems needed to synthesize or develop decision support systems for the purpose of helping the healthcare management process achieve better outcomes in healthcare delivery
Health informatics
completed whenever an incident occurs
Incident (occurrence) report
involves the use of data-action-response (DAR) notes. Incorporates all aspects of the nursing process, highlights a patient’s concerns, and can be integrated into any clinical setting
Focus charting
refers to the management and processing of information, generally with the assistance of computers
Information technology (IT)
a portable “flip-over” file or binder, kept at the nursing station
Kardex
oral, written, or audio-recorded exchanges of information between caregivers
Reports
unexpected occurrences, unmet goals, and interventions not specified within the clinical pathway time frame
Variance
standardized bedside safe patient handoffs describes patients’ health status and tells staff on the next shift what care patient needs
Transfer of accountability (TOA)
required when patients are transferred from one unit to another to receive different levels of care
Transfer report
the patient’s chart is organized so that each discipline (e.g. nursing, medicine, social work, respiratory therapy) has a separate section in which to to record data
Source record
pre-developed guides by the nursing staff and health care agencies to ensure that patients with a particular condition receive consistent care
Standardized care plans
SOAP note
Subjective data, objective data, assessment, plan
SOAPIE note
Subjective data, objective data, assessment, plan, intervention, evaluation
incorporates the principles of nursing informatics to support he work that nurses do by facilitating the documentation of nursing process activities and offering resources for managing nursing care delivery
Nursing clinical information system (NCIS)
share important patient information in an effective and efficient way and to help standardize communication
Identification-situation-background-assessment-reccomendation-repeat back (I-SBAR-R) technique
AKA medical record, health record, or chart - a confidential, permanent legal document of information relevant to a patient’s health care
Patient record
PIE format
Problem, intervention, evaluation
an arrangement for services by another healthcare provider
Referrals
federal legislation that protects personal information, including health information.
Personal Information Protection and Electronic Documents Act (PIPEDA)
a system for organizing documentation that places the primary focus on the patients’ individual problems
Problem-orientated medical record (POMR)
