Exam 1 Flashcards

1
Q

Second phase of the nursing process

A

Diagnosis

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2
Q

The action phase

A

Implementation

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3
Q

1st phase of the nursing process

A

Assessment

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4
Q

Based on the pt’s response to health problems

A

Diagnosis

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5
Q

Includes the history and physical exam

A

Assessment

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6
Q

Divided into two phases

A

Planning

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7
Q

Determine whether the outcomes were met

A

Evaluation

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8
Q

The problem

A

Diagnosis

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9
Q

Includes test results and lab values

A

Assessment

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10
Q

Based on evidence-based care standards

A

Implementation or Planning

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11
Q

Data gathering phase

A

Assessment

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12
Q

Document actions and patient response

A

Implementation

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13
Q

Includes outcomes and interventions

A

Planning

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14
Q

Based on a review of the assessment data

A

Diagnosis

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15
Q

Care plan is modified

A

Evaluation

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16
Q

Hypothesis is made

A

Diagnosis

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17
Q

Delegation occurs

A

Implementation

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18
Q

Finished product is a care plan

A

Planning

19
Q

4 purposes of Nursing

A

Promote Health
Prevent Illness
Restore Health
Advocacy

20
Q

Promote Health

A

Education, encouragement, diet plans, exercise

21
Q

Prevent Illness

A

Hygiene, Dr’s 1st set of eyes, vaccinations, screenings

22
Q

Restore Health

A

Position changes, bandage changing

23
Q

Advocacy

A

When pt is in pain, notice cues and verbal changes, providing resources

24
Q

What is the ANA?

A

American Nurses Association
Code of ethics, scope standards, advocacy, ethics, quality of practice

25
Q

What is PT, OT, and RT?

A

Physical Therapy- focuses on improving pt body movement

Occupational Therapist- focuses on pts ability to perform daily activities

Respiratory Therapist- give pts oxygen, lung performance

26
Q

Roles and Functions of the Nurse

A

Direct care provider . Leader
Communicator Change agent
Teacher/educator. Manager
Client advocate. Case Manager
Counselor. Research consumer

27
Q

Definition of the Nursing Process

A

A systematic problem-solving process for the delivery of care

28
Q

Purpose of the Nursing Process

A

To help the nurse provider goal-directed, client-centered care

29
Q

What are the phases of the Nursing process?

A

1. Assessment
2. Diagnosis
3a. Planning Outcomes
3b. Planning Interventions
4. Implementation
5. Evaluation

30
Q

1st Phase of Nursing

A

Assessment- Gather data
Asses the patient
Subjective/objective
Primary/secondary
Health Hx

31
Q

2nd Phase of Nursing Process

A

Diagnosis-
Identify pts health needs
Dx from NANDA
Prioritize (Maslows ABCs)
. Pick one
. Nursing Dx

32
Q

3rd Phase of Nursing Process

A

A. Planning outcomes-
. Decide goals to achieve
(measurable)
B. Planning interventions-
Chose intervention to achieve goals

33
Q

4th Phase of Nursing Process

A

Implementation-
Document
Action phase. Do it!
Delegations

34
Q

5th Phase of the Nursing Process

A

Evaluation-
Final phase
Judge if actions successfully treated pts problems
Yes/No- Assessment

35
Q

Clinical Judgement Model

A

NCJMM
Built on & expands nursing process
Evidence based
Identifies 6 cognitive skilled needed to make clinical judgements

36
Q

NCJMM 6 cognitive skills

A

Recognize cues
Analyze cues
Prioritize hypotheses
Generate solutions
Take action
Evaluate Outcomes

37
Q

NCJMM Step 1

A

Recognize Cues (Assessment)-
Data gathering
Subjective- what pts says (sx)
Objective- what professionals say (observations & labs, CT, MRI)
Primary (pt)
Secondary (spouse, health record)

38
Q

Different types of assessments

A

Initial- 1st appointment, ED
Ongoing- CA, vitals q 4hrs, pain management
Comprehensive- whole body, spiritual
Focused- ABD Pain (start with GI)
Special needs- nutritional, cultural, psychosocial, family, wellness

39
Q

When do you validate data?

A

Subjective & objective do not agree
Data falls out of nl range
Pts statement changes

*Once you get your data, document it*

40
Q

NCJMM step 2

A

Analyze cues/hypotheses (Diagnose)-
Identify patterns
Draw conclusion to identify pts health status

41
Q

Medical Diagnosis

A

Describes illness, injury, or disease
Remains constant unless cured
Made by Drs, NP, and PAs

42
Q

Nursing Diagnosis

A

Focuses on responses or health problems
(N/V now under control… can change)
NANDA nursing Dx
(Self care deficit, impaired urinary elimination)

43
Q

Components of NANDA Nursing Diagnosis

A

Type of Nursing Dx-
Problem focused, health promotion, at risk
Problem-
NANDA Dx
Etiology- (r/t related to)
Related or risk factor or cause
Signs & Symptoms- (AEB as evidence by)
Cluster of symptoms that support Dx