FUNDA LAB NCP (1) Flashcards
The nursing process is modified as
scientific method
Nursing practice was first described as a five-stage nursing process by ____ it should not be focused with NURSING THEORIES OR HEALTH INFORMATICS
ida jean orlando (1958)
is a systematic problem-solving approach used to identify, prevent and treat actual or potential health problems and promote wellness
nursing process
- to identify a client’s health status and actual or potential health care problems or needs
- to establish plants to met the identified needs
- to deliver specific nursing interventions to meet those needs
purposes of nursing process
Developed the Nursing Process as we know it today is based upon the “Deliberative Nursing Process Theory”.
ida jean orlando pelletier
Nurses use the standard nursing process in Orlando’s Nursing Process Discipline Theory to _________
produce positive outcomes or patient improvement.
____ Is a critical thinking process that professional nurses use to apply the best available evidence to caregiving and promotion human functions and responses to health and illness
Nursing process (ANA 2010)
characteristics of nursing process
cyclic
dynamic nature
client centeredness
focus on problem solving and decision making
interpersonal and collaboration style
universal applicability
use of critical thinking and clinical reasoning
-is a unique approach or the nursing process that requires CARE RESPECTFUL of and responsive to the individual patient’s needs, preferences, values. The nurse functions as PATIENT ADVOCATE by keeping the patient’s right to practice informed decision making and maintaining ______ engagement in the health care settimg
patient-centered
the nursing process provides the basis for the therapeutic process in which the nurse and patient RESPECT EACH OTHER as an individual, both of them learning and growing due to the interaction, It involves the INTERACTION BETWEEN the nurse and the patient with a common goal
interpersonal
the nursing process functions effectively in nursing and inter-professional teams, promoting open communication, mutual respect and SHARED decision making to achieve quality patient care
collaborative
the nursing process is a ________ process in which EACH PHASE INTERACTS with and is influenced by the other phases
dynamic and cyclical
the use of the nursing process requires _______ which is a vital skill required for nurses in IDENTIFYING CLIENT PROBLEMS AND IMPLEMENTING INTERVENTIONS to promote effective care outcomes
critical thinking
is the systematic and continuous collection, organization, validation and documentation of data (information)
assessment
performed within SPECIFIED time after admission. to establish a complete database for problem identification (ex: nursing admission assessment)
initial nursing assessment
to determine the status of a SPECIFIC PROBLEM identified in an earlier assessment (ex: hourly checking of vs)
problem-focused assessment
during EMERGENCY SITUATION to identify any LIFE THREATENING situation (rapid assess of indiv airway and breathing status)
emergency assessment
several month after initial assessment. to COMPARE the client’s current health status with the data PREVIOUSLY obtained
time-lapsed reassessment
The nurse completes a holistic nursing assessment of the needs of the individuals/family/community, regardless of the reason for the encounter. The nurse collects SUBJECTIVE AND OBJECTIVE DATA using a nursing framework such as MARJORY GORDON’s functional health patterns
true
is the process of gathering information about a client’s health status. it includes the health history, physical examination, results of laboratory and diagnostic test and material contributed by other health personnel
data collection/collection of data
also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person (ex; itching, pain, feelings)
subjective data
also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. they can be seen, heard,smelled. ex: a discoloration of a skin or a bp reading
objective data
it is the direct source of information.
primary
it is the indirct source of information. all sources other than the client are considered ______ like family members, health prof, records, lab, diagnostic
secondary data
it is gathering data by using the senses. vision smell and hearing are used
observation
an _____ is planned communication or s conversation with a purpose
interview
the physical _____ is a systematic data collection method to detect health problems. to conduct it, the nurses uses techniques of inspection, palpation, percussion and auscultation
examination
the nurses uses a format that organizes the assessment data systematically. this is often referred to as nursing health history or nursing assessment form
organization of data
the information gathered during the assessment is “double-checked” or verified to confirm that is is accurate or complete
validation data
to complete the assessment , the nurse records client data. accurate documentation is essential and should include all data collected about the health status
documentation data
- analyze data
- identify health problems, risks, and strength
- formulate diagnosis statements
diagnosing
“a clinical judgement concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community”
NANDA
is the second phase of the nursing process, in this phase, nurses use critical thinking skills to interpret assessment data to identify client problems
diagnosis
MEANING OF NANDA
north american nursing diagnosis association
This phase in the nursing process is one of the most important. We must consider all external factors of the patient (environmental, socioeconomic, and physiological etc.) when developing a diagnosis, which can be challenging at times.
nursing diagnosis
it is a client problem that is present at the time of the nursing asses
actual diagnosis
relates to client’s preparedness to improve their health condition
health promotion diagnosis
is a clinical judgement that a problem does not exist, but pt the presence of risk factors indicates that a problem may develop if adequate care is not given
risk nursing diagnosis
3 components of NANDA
problem statement, etiology, defining characteristics
component of a nursing diagnosis identified causes of the health problem
etiology
component of a nursing diagnosis identifies causes of the health problem
etiology
describes the client’s health problems
problem statement
are the cluster of signs and symptoms that indicate the presence of health problem
defining characteristics
- prioritize problems/diagnoses
- formulate goals/desired outcomes
- select nursing interventions
- write nursing interventions
planning
- it involves decision making and problem solving
- it is the process of formulating client goals and designing the nursing interventions required to prevent, reduce or eliminate the client’s health problems
planning
planning which is done after the initial assessments
initial planning
it is a continuous planning
ongoing planning
planning for needs after discharge
discharge planning
nurses frequently use ________ of needs when setting priorities
maslow’s hierarchy
what are the 5 maslow’s hierarchy starting from lower to upper
physiological needs
safety needs
belongingness and love needs
esteem needs
self actualization
it can be achieved in a reasonable amount of tike (few hours to de days)ex:8hrs
short term
this may take weeks/months to be achieved
long term
a ______ is any treatment, that a nurse performs to improve patient’s health
nursing interventions
the process of implementation includes
implementing the nursing interventions and documenting nursing activities
Any intervention that the nurse can independently provide without obtaining a prescription is considered an _______ An example of an _______ nursing intervention is when the nurses monitor the patient’s 24-hour intake/output record for trends because of a risk for imbalanced fluid volume.
independent nursing interventions
require a prescription before they can be performed. Prescriptions are orders, interventions, remedies, or treatments ordered or directed by an authorized primary health care provider. A primary health care provider is a member of the health care team (usually a physician, advanced practice nurse, or physician’s assistant) who is licensed and authorized to formulate prescriptions on behalf of the client. For example, administering medication
dependent nursing interventions
“The nurse will reposition the patient with dependent edema frequently, as appropriate.”
independent nursing interventions
are actions that the nurse carries out in collaboration with other health team members, such as physicians, social workers, respiratory therapists, physical therapists, and occupational therapists. These actions are developed in consultation with other health care professionals and incorporate their professional viewpoint.
collaborative nursing interventions
“The nurse will administer scheduled diuretics as prescribed.”
dependent nursing interventions
“The nurse will administer scheduled diuretics as prescribed.”
collaborative nursing interventions
is a written or computers information about the client’s care
nursing care plan
action performed to client (inserting foley catheter)
direct care interventions
actions performed away from client ( looking at lab results)
indirect care interventions
- putting your plan into action
- set priorities after report
- assess and reassess /revise or review
- perf interventions
- chart client response
- give report to next shift
- organize resources and care delivery
implementation
is a planned, ongoing, purposeful activity in which the nurse determines
(a) the client’s progress toward achievement of goals/outcomes and (b) the effectiveness of the ncp
evaluation
