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Foundations Of Nursing > Chapters 3,5 and 6 > Flashcards

Chapters 3,5 and 6 Flashcards

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1
Q

During which phase of the nursing process does documentation take place?

A

Implementation

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2
Q

When charting by exception, which acronym is generally used?

A

PIE

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3
Q

What are nursing interventions?

A

Activities that promote the achievement of desired patient goal

(Classified as physician-prescribed or nurse-prescribed)

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4
Q

What is nurse initiated/dependent interventions?

A

Legally autonomous actions to benefit clients (DO NOT NEED ORDER)

Ex: turning and repositioning every 2 hours, ambulating, I&O monitoring intake, encouraging fluids, monitoring for complications

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5
Q

What is provider-initiated/dependent interventions?

A

Providers prescription(written, standing or verbal) or the facility’s protocol (blood administration procedures)

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6
Q

What is collaborative interventions?

A

Collaboration with other health care team professionals

Ex: diet and speech

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7
Q

What is nursing process?

A

Cyclical
Systematic method
Scientific
Critical thinking process (DECISION MAKING FRAMEWORK FOR ORGANIZING CARE)
Purposeful
Goal-directed
Way to achieve optimal client outcomes through planning and providing

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8
Q

What are the SIX phases of the nursing process?

A 
🔴 Assessment
🔴 Diagnosis 
🔴 Outcomes identification 
🔴 Planning 
🔴 Implementation 
🔴 Evaluation
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9
Q

Define assessment?

A

🔺Primary goal is to collect data🔺

A systematic process to collect and analyze information about clients health to identify needs and additional data to collect based on findings

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10
Q

What are the 2 types of data?

A

Objective - observable, measurable finding the NURSE collects

Ex: VS, lab work, assessment findings (lung sounds, skin color, etc)

Subjective - self reported by the patient

Ex: pain, feelings, sensations, dizziness, palpitations, nausea, etc

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11
Q

What are the sources of data?

A

Primary and secondary

Primary is the PATIENT

Secondary:
Family(spouse, parents and children)
Med records
Other healthcare providers
Diagnostic studies (X-ray, MRI)
Lab work
Nurse Shift report
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12
Q

Methods of data collection?

A 
Interview
Physical exams:
Focused (problem oriented)
Comprehensive/complete head to toe (review of ALL systems, done on assessment)
Observation 
Medical history 
Diagnostic and lab reports
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13
Q

What is acute conditions?

A

Rapid onset
Limited duration of time
Can become chronic if unresolved

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14
Q

What is chronic conditions?

A

Always present or consistently reoccur

Last at least 3 months or longer

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15
Q

Define data clustering?

A

Method of data organization (defining characteristics)
Related cues are grouped together
Helps to identify patterns and select most appropriate diagnosis

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16
Q

RN vs LPN Assessment

A

RN is responsible for the INITIAL assessment

LPN assists with ongoing assessment

17
Q

What is nursing diagnosis?

A

Identification of human response to health problems and life processes

Can be treated by the nurse

Written using NANDA

LPN assists

18
Q

Types of nursing diagnoses and examples?

A

Actual (present now) TAKES PRIORITY
EX: acute pain

Potential/At risk (possible in the future
Ex: at risk for acute pain

Collaborative problems (involve other disciplines

Health promotion (willingness)
Ex: readiness for enhanced nutrition
19
Q

What is medical diagnosis and examples?

A

Identification of disease or condition
Healthcare provider is licensed to diagnose and treat

Ex: congestive heart failure, diabetes Miletus, myocardial infarction

20
Q

How to formulate nursing diagnosis?

A

Use NANDA
Chosen based on defining characteristics
Identify patient’s problems rather than your problems with nursing care as a nursing diagnosis
IT CANNOT CONTAIN MEDICAL DIAGNOSIS

21
Q

How to prioritize nursing diagnosis?

A

Actual problems may be ranked before risk problems
Use Maslow to prioritize diagnoses
Unstable before stable
Acute before chronic
Life threatening before non-life- threatening
Unexpected before expected

22
Q

What are the parts of nursing diagnosis and give examples?

A 
Actual - problem exists
🔴 3 part statement 
1. Problem statement 
2. Related to (contributing factors)
3. As evidenced by (specific S&S)

Ex: infrequent bowel elimination related to insufficient water intake as evidenced by no vowel movement in 5 days

Potential/at risk
Problem can happen in a future (strong possibility)
🔴 2 part statement
1. Potential Problem statement
2. Related to (risk factors)

Ex: at risk for compromised skin integrity related to immobility

23
Q

Define culture?

A

Set of values, benefits, customs and practices (similarities shared among members)
Learned from birth through socialization
Adaptation to specific condition/location
Evolves overtime (dynamic and ever-changing but stable)
Shared by a group
Passes from one generation to another
Can be linked by ethnicity, race, nationality, language, religion, location, sexual orientation, class or gender

24
Q

Define subculture?

A

Share characteristics with the primary culture

Has characteristic patterns of behavior and ideals that distinguish it from the rest of cultural groups

25
Q

Define society?

A

A nation, community or broad group of people who establish particular aims, beliefs or standards

26
Q

What is transcultural nursing?

A

Culture competence
Understand and address the entire cultural context of each client, integrate culture into all aspects of care
Need to develop to be able to function effect in multi-cultural environment
Assess for preferred language, provide teaching in language spoken
Encourage family to participate in care as appropriate

27
Q

What is a teach back method?

A

A method used to evaluate patient teaching
Used to verify or evaluate a patient’s understanding after you explains something to them
Ask them to repeat information back to you

28
Q

What is the planning stage involve?

A

Identify nurse interventions

Ex: scheduling fluid intake for a patient on dehydration- give fluids every hour while awake

29
Q

What is needed to identify the needs of the patient and design care?

A

Individualized care plan

30
Q

What is the best time to document nursing care?

A

As soon as it’s completed

31
Q

What are the guidelines for documentation?

A

Accurate and complete
Date and time on all entries
Should be detailed and document only facts-because it is a legal record
Never chart for others
Chart facts/objective/descriptive data and not opinions
Document immediately after completion of care
Do not erase or scratch or apply correction fluid
Do not record “physician made an error”
Use only facility abbreviations
Use black ink
Begin entry with time and end with signature
For late entry write “late entry, 1/1/16…
When you make an error, draw one line across, put your initials or sign your name on top and write the correct entry beside it

32
Q

What is an incident report form?

A

A form that explains any event that are not consistent with facility or national standards

33
Q

What are the guidelines for filing out a incident report?

A

Description of the injury, including diagrams of the injury
Date, time and location
Name of physician and family member notified
Chronologic order of the event

34
Q

What does a therapeutic communication accomplish?

A

Facilitates a positive nurse-patient relationship

35
Q

What is included in a medical record?

A

A patient’s nursing problems, medical problems, care planned for the patient, care given to the patient, and patient’s response to treatment

36
Q

Examples of incidences/occurrences that s nurse would include in an incident report?

A

Falls, omission of prescription, needle stick injuries, medication errors, omission of therapies, a visitor who exhibits symptoms of communicable disease

37
Q

When should we use patient as the main source of data?

A

When assessing variables from a cultural perspective

38
Q

Muslim women prefer to be cared by?

A

Female providers

39
Q

Before a nurse could provide patient-centered and culturally competent care, what should the nurse do first?

A

Assess your own biases (prejudices) and attitudes

Foundations Of Nursing (2 decks)

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