Lecture 6 - The Nursing Process Flashcards

1
Q

What are the two professional nursing organizations in Canada?

A

–> Canadian Nurses Association (CNA)
–> Canadian Nurses Protective Society (CNPS)

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1
Q

What is the role of professional nursing organizations in Canada?

A

To serve as official representative of the nursing profession and interact with government officials on issues concerning the health of a population.

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2
Q

What is the professional regulatory body for Canadian nurses?

A

College of Nurses of Ontario (CNO)

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3
Q

Which professional union exists for all Canadian nurses?

A

Canadian Nurses Association (CNA)

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4
Q

What is critical thinking?

A

A process and set of skills, includes the use of knowledge and reasoning to make accurate clinical judgements and decisions.

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5
Q

What are the steps of a critical thinking process?

A

–> Recognizing the client’s health problem or concern
–> Analyze data
–> Review assumptions and evidence
–> Explore alternative solutions and prioritize the client’s preferences
–> Consider ethical principles
–> Draw conclusions on how to proceed

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6
Q

What is basic critical thinking?

A

–> Thinking is concrete and based on a set of rules or principles
–> Rigid, black and white thinking with little flexibility for patient preferences or comfort

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7
Q

What is complex critical thinking?

A

–> Begin to separate one’s own thinking from those of other experts
–> Realize that alternative and conflicting solution to a problem can exist - one must weigh the benefits and risk.

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8
Q

What is the commitment level of critical thinking?

A

When one anticipates the need to make choices without assistance from other professionals, then assumes responsibility and accountability to those choices.

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9
Q

What are the five components of critical thinking?

A

–> Specific Knowledge base
–> Experience
–> Competencies
–> Attitudes
–> Standards

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10
Q

The analysis of data, the diagnosis, etiologies, current plans, and implemented interventions are part of which step in the nursing process?

A

Evaluation

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11
Q

Data analysis, problem identification, and label are part of which step in the nursing process?

A

Diagnosis

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12
Q

Priority and goal setting is part of which step in the nursing process?

A

Planning

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13
Q

Nurse-initiated and physician initiated treatments are part of which step in the nursing process?

A

Implementation/intervention

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14
Q

Subjective and objective data are part of which step in the nursing process?

A

Assessment

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15
Q

What is nursing assessment?

A

The systematic and deliberate collection of data to determine a client’s current and past health status and functional status to determine the client’s present and past coping patterns.

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16
Q

What are primary sources of information?

A

The client

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17
Q

What are secondary sources of information?

A

–> Family and significant others
–> Health care team
–> Medical records

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18
Q

What are tertiary sources of information?

A

–> Literature
–> Nurse’s experience

19
Q

What is the first step in a nursing assessment?

A

The Interview
–> Introduce oneself, and explain role as HCP
–> Establish therapeutic relationship
–> Obtain Insight about client’s concerns or worries
–> Determine the client’s goals and expectations
–> Obtain cues about what may require furthur assessment

20
Q

What is the second step in a nursing assessment?

A

Collecting Health History
–> Bio
–> AMPLE
–> Psychological, spiritual, sociocultural, developmental variables
–> Current state of health and reason for interview

21
Q

What is the third step in nursing assessment?

A

Physical Assessment

22
Q

What is done during data analysis and interpretation?

A

Data validation and recognition of patterns and trends.
Comparing with normal trends is also helpful.
All of this is needed for appropriate clinical decision making

23
Q

What is the purpose of a nursing diagnosis?

A

To determine the client’s health problems that are within the domain of nursing, in order to decide what care the client should receive

24
Q

What is the difference between a medical and nursing diagnosis?

A

A medical diagnosis is the identification of a disease condition based on specific evaluation of signs and symptoms

A nursing diagnosis is a clinical judgement about a client’s response to an actual or potential health problem

25
Q

What is a collaborative problem?

A

An actual or potential complication that nurses monitor to detect a change in the client status

26
Q

What is NANDA? What is their mission?

A

North American Nursing Diagnosis Association
–> Mission is to facilitate the development, refinement, dissemination, and use of the standardized nursing terminology

27
Q

What is NANDA’s purpose?

A

–> TO determine precise definitions and a common language among the profession
–> To allow for clear communication
–> To distinguish the nurse’s role

28
Q

What is an Actual Nursing Diagnosis?

A

One that describes responses to health conditions or life processes that exist in an individual, family, or community

29
Q

What is a Risk Nursing Diagnosis?

A

One that describes responses to health conditions of life processes that may develop.

30
Q

What is a Health Promotion Nursing Diagnosis?

A

A clinical judgement of a person’s family’s or community’s motivation and desire to increase well-being by readiness to enhance specific health behaviours, such as nutrition and exercise

31
Q

What is a Wellness Nursing DIagnosis?

A

One that describes the levels of wellness in an individual, family, or community that can be enhanced.

32
Q

What is the difference between a health promotion nursing diagnosis and a wellness nursing diagnosis?

A

A wellness nursing diagnosis describes wellness that can be enhanced, whereas a health promotion diagnosis can be used in any state and no not necessarily reflect current levels of wellness.

33
Q

The following statement is an example of which kind of nursing diagnosis?

Risk for infection related to a site for organism invasion secondary to surgery

A

Risk Nursing Diagnosis

33
Q

What are the three components of an Actual Nursing Diagnosis?

A

Problem
–> From NANDA-I list)
Etiology
–>Related cause or contributor to the problem
Symptoms
–> As described by patient

[Diagnosis label] related to [Etiology] as evidences by [symptoms]

33
Q

What are the two components of a Risk Nursing Diagnosis?

A

Diagnosis
–> Taken from official NANDA=I list

Related Factors
–> Risk factors

[Diagnosis Label] related to [Risk factor]

33
Q

The following statement is an example of which kind of nursing diagnosis:

Acute pain related to stress on surgical area during movement as evidences by patient report, elevated heart rate, and BP

A

Actual Nursing Diagnosis

34
Q

What is the only component of a health promotion or wellness nursing diagnosis?

A

The official label from NANDA-I list

35
Q

The following statement is an example of which kind of nursing diagnosis:

Readiness for enhanced self-care

A

Health Promotion / Wellness

36
Q

What is the difference between a goal and expected outcome?

A

A goal represents the predicted resolution of nursing diagnosis or health problem, whereas expected outcome is the measurable criteria to evaluate goal achievement.

These may be combined

37
Q

What are the the three types of interventions?

A

Independent
–> Nurse initiated
Dependent
–> Physician initiated
Collaborative
–> Interdependent

38
Q

Which six factors must be considered when selecting interventions?

A
  1. The nursing diagnosis
  2. Expected outcomes
  3. Evidence base for interventions
  4. Feasibility of the intervention
  5. Acceptability to the client
  6. Nurse’s competency
39
Q

Who developed the Nursing Interventions Classification (NIC)?

A

The Iowa Intervention Project

40
Q

What are four important components of the implementation step of the nursing process?

A

–> Reassessing the client
–> Reviewing and revising existing nursing care plan
–> Organizing resources and care delivery
–> Anticipating and preventing complications

41
Q

What is indirect care? What are some examples?

A

Indirect care are actions that support the effectiveness of direct care intervention, such as:
–> Communicating nursing interventions
–> Documentation
–> Medical order transcription
–> Infection control
–> Computer data entry
–>Delegation, supervision, and evaluation of the work of staff members

42
Q

What are the five elements of evaluation in nursing care?

A
  1. Identify evaluative criteria and standards
  2. Collect evaluate data
  3. Interpret and summarize findings
  4. Document findings and clinical judgements
  5. Terminate, continue, or revise the care plan.