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INTRO TO NURSING > EXAMS 2 > Flashcards

EXAMS 2 Flashcards

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1
Q

what does nursing care plans provide

A

provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes.

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2
Q

what is Informal nursing care plan

A

a strategy of action that exists in the nurse’s mind

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3
Q

what is formal nursing plan

A

a written or computerized guide that organizes information about the client’s care.

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4
Q

what are Nursing Care Plans Concept Maps

A

Utilize the Nursing Process to construct an individualized plan of care for a patient based on a critical analysis of patient assessment data

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5
Q

what is the Nursing Process

A

Systematic method of giving humanistic care that focuses on achieving outcomes in a cost effective manner.

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6
Q

characteristics about nursing care plans

A
  • Written guidelines for client care
  • Organized so nurse can quickly identify nursing actions to be delivered
  • Coordinates resources for care
  • Enhances the continuity of care
  • Organizes information for change of shift report
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7
Q

The Nursing Process is a Systematic Five Step Process what are they?

A

ADPIE

Assessment
Diagnosis
Planning
Implementation
Evaluation
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8
Q

what is ASSESSMENT of the nursing process

A

What data is collected?The first step of the nursing process.

  • Gather data.
  • Important information is through an interview.
  • Physical examinations.
  • Includes reviewing patient’s health history, surgical history, family history, and any general

includes manifestations of the pain. using nursing process to know they have a blocked artery etc

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9
Q

what is DIAGNOSIS of the nursing process

A

what is the problem?

USING OF JUDGEMENT TO IDENTIFY POTENTIAL CAUSE, HEALTH NEEDS OR CONDITIONS

  • Diagnosing involves a nurse making an educated judgment about a potential or actual health problem with a patient.
  • More than one diagnoses are sometimes made for a single patient.
  • not every
    nursing diagnosis is accompanied by potential complications
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10
Q

what is PLANNING in the nursing process

A

How to manage the problem?

  • Each problem is committed to a clear, measurable goal for the expected beneficial outcome
  • S.M.A.R.T Goals
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11
Q

S.M.A.R.T Goals

A

Specific
Measurable
Achievable
Realistic Timely

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12
Q

IMPLEMENTATION of the nursing process

A
  • Putting the plan into action
  • Interventions should be specific to each patient and focus on achievable outcomes.
  • Actions associated in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.
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13
Q

EVALUATION of the nursing process

A

Did the plan work?

  • Once all nursing intervention actions have taken place evaluate what was the impact on the patient.
  • Did the patient’s condition improved, the patient’s condition stabilized, or the patient’s condition worsened.
  • If goals were not met, the nursing process begins again from the first step
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14
Q

Using the Nursing Process for Care Plans

A
  • Requirement set forth by national practice standards (ANA, TJC)
  • Basis for NCLEX exams
  • Based on principles and rules that promote critical thinking in nursing
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15
Q

5 Activities Needed to Perform a Systematic Assessment

A
  • Collect data
  • Verify data
  • Organize data
  • Identify Patterns
  • Report & Record data
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16
Q

Comprehensive Data CollectionComprehensive Data Collection

A
  • Begins before you actually see the patient (Nurse report, Chart reviews)
  • Continues with admission interview and physical assessment once you meet patient.
  • Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing literature.
  • Consider age, growth & development
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17
Q

What’s Important Data?

A 
Name, age, gender, admitting diagnosis
Family or support person present 
Appropriate to share information 
Medical/surgical history, chronic illnesses
Advanced Directives, DNR, Healthcare Surrogate
Laboratory Data/Diagnostic tests
Medications current and past 
Allergies and what happens?
Psychosocial/Cultural Assessment
Emotional state
Comprehensive Physical Assessment
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18
Q

Comprehensive Physical Assessment

A
  • Vital signs
  • Height & weight
  • Review of systems (neurological/mental status, musculoskeletal, cardiovascular, respiratory, GI, GU, skin and wounds.
  • Standardized risk assessments
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19
Q

importance of clustering data

A

Clustering data helps maintain a nursing focus, allows patterns to be recognized

  • Cluster data into groups according to a nursing (Maslow’s Basic Human Needs Model)
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20
Q

how should clustering be done

A

Cluster by body system or need deficit

  • Example: All information gathered regarding nutritional status may help to identify nutritional alterations
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21
Q

PRIOTIZING physiological needs

A
  • Airway
  • Breathing
  • Circulation
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22
Q

what are the Novice nurse responsible for

A
  • Novice nurse responsible for recognizing health problems, anticipating complications, initiating actions to ensure timely and appropriate treatment.
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23
Q

what is the APN role

A

Laws & standards continue to change to reflect how nursing practice is growing

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24
Q

what is Nursing Diagnosis

A

Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved

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25
Q

Identifying Nursing Diagnosis

A
  • Common language for nurses
  • A clinical judgment about an individual, family or community response to an actual or potential health problem or life process
  • NANDA list of acceptable diagnoses, updated every 2 years.
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26
Q

Diagnostic Reasoning

A
  • Apply critical thinking to problem identification
  • Requires knowledge, skill, and experience
  • Big Picture
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27
Q

Fundamental Principles of Diagnostic Reasoning

A
  • Recognize diagnoses
  • Keep an open mind
  • Back up diagnosis with evidence
  • Intuition is a valuable tool for problem identification
  • Independent thinker
  • Know your qualifications & limitations
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28
Q

the 4 types of nursing diagnosis

A
  • Actual (Problem-Focused)
  • Risk
  • Health Promotion - Syndrome.
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29
Q

difference between actual and potential diagnosis

A

ACTUAL: actual evidence of signs/symptoms of diagnosis exist. (Fluid Volume Deficit)

POTENTIAL/RISK: client’s data base contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity)

30
Q

writing a nursing diagnosis

A
  • Don’t state 2 separate problems in one diagnosis
  • Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)
  • Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)
  • refer to NANDA list in a nursing text books
31
Q

Planning: 4 Part Process

A
  • Set your priorities of care, what needs to be done first, what can wait.
  • Apply Nursing Standards, Nurse Practice Act, National practice guidelines, hospital policy and procedure manuals.
  • Identify your goals & outcomes, derive them from nursing diagnosis/problem.
  • Determine interventions, based on goals.
  • Record the plan (care plan/concept map)
32
Q

example of short term goal

A

Client will ambulate down the hall within 2 days.

33
Q

example of long term goal

A

Client will walk the length of the hallway independently by the end of 2 weeks

34
Q

Achieving Goals/Outcomes

A
  • Be realistic in setting goals. (look at overall health state, growth & development level, prognosis)
  • Set goals mutually with client
  • Goals should be measurable, use measurable, observable verbs
  • Identify one behavior per outcome
  • When indicated use short-term vs. long tern goals
35
Q

Determining Interventions

A

Interventions will be collaborative, combining nursing actions and physician orders.

EXAMPLE: PATIENT WITH INEFFECTIVE AIRWAYS CLEARANCE RELATED TO INCISIONAL PAIN

  • Nursing Actions: Ascultate breath sounds every four hours, Assist with coughing and deep breathing every hour etc.
    Physician orders: pain medication, activity orders
36
Q

achieving outcomes

A
  • Identify one behavior per outcome
  • Be realistic in setting goals. (look at overall health state, growth & development level, prognosis)
  • Set goals mutually with client
  • Goals should be measurable, use measurable, observable verbs
37
Q

Implementation

A
  • Putting your plan into action
  • Set priorities after report
  • Assess and reassess
  • Perform interventions
  • Chart client responses
  • Give report to next shift
38
Q

Implementation of Nursing Interventions

A
  • Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed
  • Action taken by nurse
39
Q

Types of Nursing Interventions

A

Protocols

Standing Orders

40
Q

what is protocol of nursing interventions

A

Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation

41
Q

what is standing orders of nursing intervention

A

Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition

42
Q

Implementation Process involves:

A
  • Reassessing the client
  • Reviewing and revising the existing care plan
  • Organizing resources and care delivery (equipment, personnel, environment)
43
Q

Evaluation of Goal Achievement

A
  • Measures and Sources: Assessment skills and techniques
  • As goals are evaluated, adjustments of the care plan are made
  • If the goal was met, that part of the care plan is discontinued
  • Redefines priorities
44
Q

Concept Map Care Plans

A
  • Innovative approach to planning & organizing nursing care.
  • Essentially a diagram of patient problems and interventions
  • Ideas about patient problems and interventions are the “concepts” to be diagrammed.
    Enhances critical thinking and clinical reasoning
  • Used to organize patient data, analyze relationships, establish priorities
45
Q

Theoretical Basis of Concept Maps

A
  • Roots in education and psychology
  • Also known as mind maps, cognitive maps
  • Concept mapping requires critical thinking
  • New knowledge is built on preexisting knowledge, new concepts are integrated by identifying relationships
46
Q

Steps in Concept Map Care Planning

A 
Develop a Basic Skeleton Diagram
Analyze and Catagorize Data
Analyze Nursing Diagnoses Relationships
Identifying Goals, Outcomes, & Interventions
Evaluate patient responses
47
Q

Maslow’s Hierarchy of Human Needs

A
  • Physiologic needs
  • Safety needs
  • Love and belonging needs
  • Self-esteem needs
  • Self-actualization needs
48
Q

Physiologic needs maslow

A 
oxygen
food
elimination
shelter
rest/bed/sleep
temperature
49
Q

what is initial comprehensive assessment

A

performed shortly after the patient is admitted to a health care agency or service

50
Q

what is the purpose of initial assessment

A

The purpose of

the initial assessment is to establish a complete database for problem identification and care planning.

51
Q

what is focused assessment

A

problem (sickness) that has already been identified.

  • It is also used to identify new or overlooked problems
  • In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has
    changed.
52
Q

what is Emergency Assessment

A

When a life-threatening physiologic or psychological crisis occurs. CPR

  • Emergency assessments are not used to establish a database for medical care, practice
    assessment skills, or help a physiologic process (such as breathing).
53
Q

what is time lapsed assessment

A

compare a client’s current status to baseline data obtained earlier

  • CURRENT HEALTH STATUS
54
Q

what is subjective date

A
  • perceived only by the affected person
  • Subjective data are those which the client can feel and describe.
  • cant be verified by the nurse
55
Q

what is objective data

A

Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person
experiencing them.

can be verified by someone else

56
Q

what is the nursing diagnosis

A

person response to medical diagnoses

57
Q

what is Validation

A

Validation is the act of confirming or verifying to plan appropriate nursing care

58
Q

what is inference

A

making a judgment that the client is confused is an inference.

An inference must be validated with subjective and/or
objective data cues.

59
Q

composing a nursing diagnosis statement

A

after the etiology, use “as defined by”

60
Q

Risk nursing diagnoses are

A
  • clinical judgments that an individual, family, or community is more vulnerable to develop
    the problem than others in the same or similar situation
  • not every
    nursing diagnosis is accompanied by potential complications.
61
Q

identify etiologies

A

factors that contribute to or

cause health problems

62
Q

Collaborative problems

A

nurses monitor to detect onset or changes in status.
Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize
the complications of the event

63
Q

common error made when writing client outcomes

A

expresses the client outcome as a nursing intervention

64
Q

critical thinking

A

“Which problems require my immediate attention or that of the team?”

  • “Which problems are most
    important to the client?”
65
Q

discharge planning

A

Begins when the patient is admitted for treatment

teaching and counseling

66
Q

Cognitive: outcomes

A

describes increases in patient knowledge or intellectual behaviors

67
Q

Psychomotor: outcomes

A

describes patient’s achievement of new skills

68
Q

Affective: outcomes

A

describes changes in patient values, beliefs, and attitudes

69
Q

Parts of a Measurable Outcome

A 
subject
Verb
Conditions
Performance criteria
Target time
70
Q

Collaborative interventions are treatments initiated by

A

other providers, such as pharmacists, respiratory therapists,
physical therapists, and other members of the health care team

INTRO TO NURSING (2 decks)

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