Fundamentals Exam 3 Flashcards
A systematic, client centered, method of providing nursing care. It provides a framework for planning and implementing nursing care.
A dynamic, continuous process, involving scientific reasoning
Used to identify, diagnose and treat human responses to health and illness
Promotes individualized nursing care
Allows you to be organized and conduct practice in a systematic way.
The nursing process
What are the 4 purposes of the nursing process
To identify client’s health status
To identify actual or potential health care problems or needs
To establish plans to meet the identified needs
To deliver specific nursing interventions to meet the needs
What are the 5 phases of the nursing process
- Assessment
- Nursing Diagnosis
- Planning
- Implementation
- Evaluation
The process of gathering, verifying and communicating data about a client. Data is gathered from a variety of sources and is the basis for actions and decisions.
Phase 1- Assessment
Begins upon admission-becomes the database
Is a continual action throughout each phase of the nursing process
Data collection (part of assessment)
Data collection involves what 4 activities
Collect data
Organize the data
Validate the data
Document data
3 methods of collecting data
- Observation
- Interview
a. Formal
b. Informal - Examination
Data is classified as either ____ or ____ data
Objective or subjective
- Factual data observed by the nurse.
- No conclusions or interpretations are made.
Examples:
B/P 100/62
Voided 200cc dark amber colored urine
Objective data
- Information given verbally by the client
- Captures the client’s point of view.
Examples:
“I itch all over.”
“My stomach aches.”
“I’m afraid of going to surgery tomorrow.”
Subjective data
What are the 2 sources of data?
Primary (the patient)
Secondary (everyone else)
Groups of related pieces of data. Grouping like we did in our first column of our care plan with mobility and skin
Data clustering
A statement that describes the client’s actual, potential or wellness human response to a health problem that the nurse is competent and licensed to treat.
Identifies health problems and provide direction for nursing care.
Places emphasis on the nurse’s independent practice.
Phase 2- Nursing diagnosis
A client problem that is present at the time of the nursing assessment.
Alteration in comfort
Ineffective breathing pattern
Impaired skin integrity
Actual nursing diagnosis (3 part statement)
Problem does not exist, but the presence of risk factors indicates a problem is likely to develop without intervention.
Risk for injury
Risk for impaired skin integrity
Risk nursing diagnosis (2 part statement)
Describes human responses to levels of wellness that have a potential for enhancement
Readiness for enhanced spiritual well being
Readiness for enhanced family coping
Wellness nursing diagnosis (1 part statement)
Evidence about a health problem is incomplete or unclear – requires more data to support or refute
Possible social isolation related to unknown etiology
Possible nursing diagnosis
The 4 types of nursing diagnosis
Possible
Wellness
Risk
Actual
Components of a nursing diagnosis statement
Statement of the problem
Etiology
Defining characteristics or the cluster of signs and symptoms (in the three part statement only)
A two part nursing diagnosis statement usually contains the words ____ ___
“related to”
Ex: risk for injury (problem) related to decreased visual acuity and decreased mobility (etiology).
This is an example of what statement?
Activity intolerance related to bedrest as evidenced by exertional dyspnea and verbal report of fatigue and weakness
Constipation related to decreased mobility and decreased fluid intake as evidenced by no BM for 3 days
3 part nursing diagnosis statement
The first part of the nursing diagnosis statement comes from the __________
- These are called “ Diagnostic Labels”
- This is a listing of the problems
- You have to add the etiology that is specific for your client.
NANDA list
The nursing diagnosis is NOT a medical diagnosis – so avoid using ______
A medical diagnosis as part of the etiology in the nursing diagnosis statement.
*Example: Activity intolerance related to congestive heart failure
The phase of the nursing process in which you develop a plan of care and determine how you are going to solve, lessen or minimize the effects of the client’s problems.
Phase 3- Planning
What are the 4 steps in the planning phase of the nursing diagnosis
**study these aside in greater detail
- Setting priorities
- Writing goals and outcome criteria
- Planning nursing interventions (derived f/the etiology)
- Writing the care plan
Phase 4 of the nursing process
Implementation
What are the 5 steps of implementation?
- Reassessing the client
- Reviewing and revising the existing nursing care plan
- Organizing resources and care delivery
- Anticipating and preventing complications
- Implementing nursing interventions
The phase of the nursing process when the planned, ongoing, purposeful activity in which clients and health care personnel determine:
- client’s progress toward achievement of goals
- the effectiveness of the nursing care plan
In this step of the nursing process, the nurse measures the client’s response to nursing interventions and the client’s progress toward achieving goals.
Phase 5- Evaluation
a discipline specific, reflective reasoning process that guides a nurse in generating, implementing and evaluating approaches for dealing with client care and professional concerns.
Critical thinking
Institutional care plans that become part of the medical record
Kardex care plans
standardized care plans for each nursing diagnosis that are individualized for the client by the nurse
Computerized care plans
Helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation
Is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care
Student care plans
Staff from all disciplines develop integrated care plans
Critical pathways care plan?
Provide a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions
Group and categorize nursing concepts to give you a holistic view of your patient’s health care needs and help you make better clinical decisions in planning care
Help you learn the interrelationships among nursing diagnoses to create a unique meaning and organization of information
Concept maps
pre-established guides for nursing care.
Standardized care plans
Laws work within nursing in what 4 ways
Providing a framework which nursing actions are legal
Differentiates nursing from other health professionals
Determines independent nursing actions
Makes nurses accountable for their actions
Legally defines & describes the scope of nursing practice
Distinguishes between nursing and medical practice
Set by every state
Specifies educational requirements for licensure
Recognizes associate, diploma, & baccalaureate
Regulates Nursing Schools
Sets standards in clinical facilities for faculty
Approves curriculum
The State Board of Nursing oversees this function
Nurse practice act
Regulates who will practice nursing
State Board of Nursing licenses nurses in the state where they practice
Mandatory ~ must have license to practice
Specifies requirements to obtain and renew license (Can also revoke license)
Gives the NCLEX exam
Some states have a multi-state licensure
Continuing education
Nurse practice act
Establishes the State Board of Nursing Responsibilities Implementing licensure laws Regulates schools of nursing Conducts license revocation hearings
Nurse practice act
8 members (appointed by the Governor for 3 year Term)
5 RNs
2 LPNs
1 resident of the state of Indiana
This makes up the…
Indiana State Board of Nursing (ISBN)
***Created by elected legislated bodies
Either Criminal or Civil
Statutory Law (Nurse Practice Act)
Concerned with behavior detrimental to society as a whole (Violation of criminal law is a crime
Criminal law
Concerned with legal rights and duties of private persons. Does not threaten society as a whole. Encourages fair and equal treatment. Violation is called a Tort. A wrong committed by a person against person or another person’s property. Examples: -negligence and malpractice-invasion of privacy-assault and battery-libel and slander
Civil law
Willful acts that violate another’s rights
Assault, Battery, Defamation
Intentional
Such as negligence of malpractice
Unintentional