chapters 33-37 & 101-103 Flashcards
The systematic method in which the nurse and client work together to plan and carry out effective nursing care (steps include assessment, nursing diagnosis, planning, implementation, and evaluation)
Nursing process
An experimental approach that test ideas to decide which methods work and which do not.
Trial and error
The basic skill of identifying a problem and taking steps to resolve it
Problem solving
Precise method of investigating problems and arriving at solutions
Scientific problem solving
Mix of inquiry, knowledge, intuition, logic, experience, and common sense.
Critical thinking
NCP
Nursing care plan
Guidelines used by healthcare facilities to plan the care for clients
Nursing care plans
The systematic and continuous collection and analysis of data/information about a client
Nursing assessment
The statement or label of the clients ACTUAL or potential problem
Nursing diagnosis
The development of goals for care and possible activities to meet them
Planning
The giving of actual nursing care
Implementation
The measurement of the effectiveness of nursing care
Evaluation
The nursing process is…
Systematic, client oriented, goal oriented, continuous, and dynamic
Specific, orderly, and logical steps based on the clients most important and vital needs
Prioritization
The needs of the client are identified, not the needs of the nurse, family or other healthcare providers
Client oriented
Goals, objectives, or expected outcomes are established as a part of the nursing process.
Goal oriented
The nursing process consists of the following steps:
Nursing assessment Nursing diagnosis Planning Implementation Evaluation
Nurses and clients work together as partners to…
Promote health
Prevent disease/illnesses
Restore health
Facilitate coping with altered functioning
In the nursing process, needs which may occur identified as “at risk for”..
Potential needs
All measurable and observable pieces of information about the client and his or her overall state of health. Only precise, accurate measurements or clear descriptions are used.
Objective data
Clients opinions or feelings about what is happening. Only the client can tell you that he or she is afraid or has pain. Communicating via body language, gestures, facial expressions
Subjective data
Things that you directly see or measure
Objective data
Things the client feels and expresses either verbally or non verbally
Subjective data
An assessment took that relies on the use of the five senses
Observation
5 senses of observation
Visual observation
Tactile observation
Auditory observation
Olfactory or Gustatory Observation
Way of soliciting information from the client
Health interview or nursing history
Interview conducted when a client is admitted to a healthcare facility
Admission interview
Physician obtaining information from an admission interview
Medical history
Documentation by nurses of care given and observations made, charting data input
Nursing progress notes
Components of nursing history/health interview
Biographical data: name age DOB
Reason for coming to facility: the primary reason or clients chief complain (CC) or perception of illness
Recent health history
Important medical history
Pertinent psychosocial information: addresses family relationships, employment, living condition
Activities of daily living (ADL)- how well client is able to meet basic needs, eating, drinking, bathing etc.
Analyzing each piece of information to determine it’s relevance to a clients health problems and it’s relationship to other pieces of information
Data analysis
NANDA
North American Nursing Diagnosis Association
Identifies the disease a person had or is believed to have which provides a basis for prognosis and treatment decisions
Medical Diagnosis
Projected client outcome
A medical diagnosis provides a basis for this and medical treatment decisions
Prognosis
Three part nursing diagnostic statement
Problem, etiology, signs and symptoms (airway clearance, excessive mucus, wheezes)
Problem, cause, symptoms
Portion of nursing diagnostic statement that describes clearly the problem the client is having
Problem
The part of the nursing diagnostic statement that is the cause of the problem
Etiology
The third part of the nursing diagnostic statement that summarizes all the data (how the client feels)
Signs and symptoms
AEB
As evidenced by
You will work together with the physician or the healthcare providers
Collaborative problem
PRN
As needed
The nursing diagnosis is a statement about the clients actual or potential health concerns that can be managed through:
Independent nursing interventions by establishing data and writing a 2-3 part diagnostic statement
The development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals
Planning
A measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care, may also be called goal or objective.
Expected outcome
Expected outcome includes:
Client oriented, specific, reasonable, measurable
An expected outcome it goal that a client can reasonably meet in a matter of hours or a few days
Short term objective
Outcome that the client ultimately hopes to achieve but which requires a longer period of time to accomplish
Long term objective
Activities (actively doing something) that will most likely produce desired outcomes (short term/long term)
Ex: teaching client deep breathe exercises, offering fluids frequently.
Nursing intervention
The entire nursing team usually formulated the nursing care plan at a meeting called…
The nursing care conference or team conference
Nursing care plan must exist within how many hours?
12-24 hours
Steps in Planning are:
Setting priorities
Establishing expected outcomes
Selecting nursing interventions
Writing a nursing care plan
The carrying out of nursing care plans, also called interventions •just do it•
Implementation
Nursing implementation performs 3 actions…
Dependent actions
Interdependent actions
Independent actions
Actions that carry out a physicians orders regarding medication or treatments (MD/physicians requires)
Dependent actions
Perform collaborative with other care providers. Interventions for collaborative problems.
Ex: a physician writes an order to give a client an enema when necessary, the nurse uses their best judgement to determine when client needs enema
Interdependent action
Nursing actions that do not require a physicians orders based on the nurses judgement (bathing, toileting)
Independent actions
A legal requirement in nursing practice in which you the nurse are responsible for all your actions you perform, whether they are dependent, interdependent, independent.
Accountability
Knowing and understanding essential information before caring for clients (critical thinking is an example)
Intellectual skills
Believing, behaving, and relating to others
Interpersonal skills
Changing a sterile dressing or administering an injection is what kind of skill?
Technical skills
Nursing implementation means the carrying out of the nursing care plan which includes 4 steps:
Putting the nursing care plan into action
Continuing the collection of data
Communicating care with the healthcare team
Document care
Communication with the health care team
Client planning conference
Or discharge planning conference (if client is being discharged)
Measuring the effectiveness of assessing, diagnosing, planning, and implementing.
Evaluation
Steps in evaluation for nursing care
Analyzing the clients responses
Identifying factors contributing to success or failure
Planning for future care (discharge planning)
3 means to evaluate the effectiveness of nursing care
the client
Team conference
Community health agencies
The process by which the client is prepared for continued care outside the healthcare facility or for independent living at home
Discharge planning
Manual or electronic account of a clients relationship with a healthcare facility
Health record
Accurate and complete documentation in a clients health record is an essential communication tool because…
Maintains communication among all caregivers
Provides written evidence of accountability
Meets legal, regulatory, and financial requirements
Provides data for research and educational purposes
Health record that supports the healthcare agency and providers have acted responsibly and effectively
Documented evidence
If it was not documented…
It was NEVER done
Standards of care (regulatory requirements for document keeping)
Record keeping
Providing safe and effective healthcare and verifying it through QA
Complete and accurate healthcare records
Financial accountability (health record)
Clients and third party payers depend on complete list of services and products provided before paying for healthcare. All treatments must be given, examinations, and special
Equipments used and recorded in health care records
Electronic documents found in a computer network
Medical information system - MIS
Electronic medical records - EMRS
Collection of various forms and documents (binder, notebook in nurses station or main administration office)
Manual health record
Documentation systems include -
EMR, MIS, or manual record/binder notebook
Health records contain four categories:
Assessment documents
Plans for care and treatment
Progress records
Plans of continuity of care
Documents that record all information about the client obtained through interview, examination, diagnostic procedures, or consultation.
Assessment documents
Long term care and some home cares use a standard form as part of the admitting nursing history / measures a clients ability to perform the activities of daily living and identifies functional losses that affect this ability
Minimum data set (MDS)
Resident assessment protocol (RAP)
Purpose for the plans of care
To ensure that all caregivers provide the same care and treatments for the client
The development of planning care used both
LPN/LVN and RNs
The physicians plan of care contains goals for treating the client and specific instructions to guide the nursing staff
Orders
A plan that specifies expected outcomes and treatments at specified times for all members of the healthcare team
Clinical care path
Establish a baseline of data Enter data at regular intervals Summarize the clients condition Document changes in clients condition Document a response to treatment.
Progress notes
Demonstrates how the nursing process and diagnoses are used to create collaboration and consistency for client care
NANDA-I
North American nursing diagnosis association international
Narrative- Chronological
Summarizes the progress of the client toward achieving his or her care plan goals
Progress or nurses notes
Type of nurses note that essentially documents what is occurring throughout the day in a chronological manner.
Narrative charting
Body system assessment starting with general observation, than assessments of the neurological, integumentary, cardiovascular, gastrointestinal, and genitourinary systems.
Head to toe charting
Type of charting used to focus on specific problems
Focus charting or area charting
The whole healthcare team works collaboratively to identify priority problems and they work collectively to solve these problems
Problem-oriented medical records (POMR)
Type of charting: SOAP
Subjective
Objective
Assessment/Analysis
Plan
SOAPIER
Subjective Objective Assessment/analysis Plan Intervention Evaluation Revision
APIE
Assessment
Plan
Intervention
Evaluation
Seperate notes by physicians, nurses, dietary, healthcare team members used as specific forms for a particular field
Documentation by discipline
Type of narrative charting that usually used a flow sheet listing body systems and their typical findings, such as lung sounds: clear, crackles, or rhonchi. The nurse checks off the correct assessment findings on a sheet
Charting by exception - CBE
This type of narrative charting would be best for a client who is physically stable with an uncomplicated care plan
Charting by exception : CBE
Emphasis is on quality care that is delivered in the most cost effective manner - also known as case studies, care mapping, critical pathway, and collaborative pathways
Case management
A graph, form, or picture that records large amounts of information collected at intervals over a specified period in brief concise entries
Graphic flow chart
Lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given
Medication administration record : MAR
Graphic flow sheet include:
Vital signs, intake and output, ADLs, dietary or eating patterns, neurological checks, restraint observation and documentation, frequent blood sugar monitoring, postoperative records, wound care and monitoring
Skills in documentation
Document what you see Be specific Use direct quotes Be prompt Be consistent Record all relevant information Respect confidentiality Record documented errors
Error in documenting/ Recorded in error - RIE
Draw a line through the statement, enclose in parenthesis and write ERROR and your initials next to it. Original note must be readable.
(mistaken entry)
AC
Before meals
ABG
Arterial blood gas
Ad lib
As desired
At liberty
AEB
As evidenced by
AMB
As manifested by
AMA
Against medical advice
Amb
Ambulate
BM
Bowel movement
BID
Twice per day
BRP
Bathroom privileges
Cc
Chief complaint
C/o
Complains of
CPR
Cardiopulmonary resuscitation
DNR
Do not resuscitate
DSG
Dressing
Dx
Diagnosis
FOB
Foot of bed
Fx
Fracture
Gtt
Drops
H or hr
Hour
HOB
Head of bed
Hx
History
I&O
Intake and output
IM
Intramuscular
IV
Intravenous
KVO, TKO
Keep vein open, to keep open
L
Left
L
Liter
LMP
Last menstrual period
MEq
Milliequivalent’s
NG
Nasogastric
NKA
No known allergies
Npo
Nothing by mouth
NS
Normal saline
N/V or N/V/D
Nausea and vomiting ; nausea, vomiting, diarrhea
O
Oral
PC
After meals
PO
By mouth
PR
Per rectum
Pulse ox
Pulse oximetry
Q, q
Every
Qh
Every hour
R, r
Respiration, rectum
rt
Right
S/P, s/p
Status post, after
STAT
Immediately
Subq
Subcutaneous
Supp
Suppository
Susp
Suspension
S&S
Signs and symptoms
Sx
Symptoms
TF
Tube feeding
TPN
Total parenteral nutrition
TPR
Temperature, pulse, respiration
TX, Tx
Treatment
VS
Vital signs
ROM
Range of motion
Caregivers move from client to client discussing important information
Walking rounds
Exchanging of information between the outgoing and incoming staff on each shift given verbally in person, in writing, or by tape recorder
Change of shift reporting
CAT
Computer adaptive test
The LPN does not perform nursing assessment per se and does independently develop nursing care plan
Good fact
The four phases of nursing process associate a to NCLEX-PN examination include:
Data collection
Planning
Implementation.
Evaluation
CLTC
Certified in long term care for lpns
A person who used specific skills such as role modeling
Leader
Coordinates and controls the work of others
Manager
Behavior used by a leader in a specific situation
Leadership style
Leader makes decisions and the group is expected to carry out orders (dictatorship)
Autocratic leadership
Leadership that relies on policies and procedure manual of the healthcare facility
Bureaucratic leadership
Guiding staff in the right direction by using a free flow of ideas, plans, and information between leaders and followers
Democratic leadership
Loosely structured goals with no firm guidelines, encourages followers to choose their own goals and plans to implement. Trying new things without fear of mistakes
Laissez- faire leadership
Writing summary evaluations of staff members (charge nurse writes this)
Performance reviews
First step if employee is showing deficiencies in due process
Oral reprimand p
If deficiency continues after oral reprimand… The second process is
Written reprimand
Procedure that ensures fair labor practices for employees and employers
Due process
A plan made for an employee who has not followed or improved deficiency after being orally and written reprimand
Plan of assistance
