Lecture One Flashcards
1
Q
Sources of data include:
A
-health history
-lab and test results
-physical assessment
2
Q
In-depth health history includes
A
-patients demographic data
-allergies and reactions
-family history of disease
-patients health promotion practices
3
Q
Types of data
A
Subjective and objective
4
Q
Contemporary influences on nursing
A
-human rights
-affordable care act
-demographic changes
-medically underserved
-healthcare costs increasing
5
Q
Loss of compassion due to burn out secondary to traumatic stress
A
Compassion fatigue
6
Q
This occurs when perceived demands purest the perceived resources
A
Burnout
7
Q
Compassion fatigue can lead to what
A
Lateral violence
8
Q
This can occur between nurses when they are overwhelmed and make rude remarks and might have negative non verbal attitude
A
Lateral violence
9
Q
The term patient can refer to who
A
-individual
-family
-community
10
Q
Benners levels of proficiency
A
-novice
-advanced beginner
-competent
-proficiency
-Expert
11
Q
Assessment involves what to form a complete database
A
-collecting info from pt or secondary source
-interpreting info
-validating info
12
Q
Two stages of assessment
A
-collection and verification of data
-analysis of data
13
Q
Sources of data
A
-patient
-family and significant others
-healthcare team
-medical records
-scientific literature
14
Q
When collecting data from a patient how will you obtain it
A
-interview - health history
-observation
-physical examination
15
Q
When collecting data from patients family what must you obtain first
A
Patients agreement
16
Q
All information obtained goes into a database including
A
-pts perceived needs
-health problems
-responses to these problems
17
Q
Types of assessments includes
A
-patient centered interview
-a physical exam
-period assessments
18
Q
Critical thinking skills allow you to __________ relevant info and use it in a purposeful way
A
Synthesize
19
Q
Information obtained through use of senses
A
Cue
20
Q
Your judgement or interpretation of cues
A
Inference
21
Q
Comprehensive patient history:
A
- General to specific
- Problem to oriented
Focus on the presenting issue
22
Q
A
23
Q
what are the phases of an interview
A
-orientation and setting an agenda
-working phase
-termination phase
24
Q
this type of interview is often used in counseling
A
motivation interviewing
25
effective communication requires what? (the four c's of communication
-courtesy
-comfort
-connection
-confirmation
26
what phase of the interview is where you introduce yourself, your position, and explain the purpose of the interview
orientation and setting an agenda
27
what phase of the interview is when you listen and gather information
working phase
28
what phase of the interview summarizes the discussion and check for accuracy
termination
29
what part of the interview do you let the patient know the interview is coming to an end and you do it in a friendly manner
termination
30
during the termination phase you let a patient know the interview is coming to end and them let the patient know what
a time frame of when you will be back to provide nursing care
31
interview techniques
-observation
-open-ended questions
-leading questions
-back channeling
-direct close-ended questions
32
this prompts the patient to describe a situation in more than one or two words
open-ending questions
33
this can be risk and can limit info to what patient thinks you want to know
leading questions
34
use of active listening prompts such as "go on"
back channeling
35
limits to yes or no or a number
direct closed-ended questions
36
this is used to clarify info we already have or have been given by the patient
direct closed-ended questions
37
to conduct an accurate and complete assessment you need to considered a patient what
cultural background
38
when cultural differences exist between you and a patient respect the unfamiliar and be ____ to a patients uniqueness
sensitive
39
a patient is admitted to the hospital with shortness of breath. As the nurse assess this patient the nurse is using the process of:
data collection
40
components of the nursing health history
-biographical info
-patient expectations
-reason for seeking health care
-present illness or health concern
-health history
-family history
-psychosocial history
-spiritual health
-review of systems
41
what is the age, address, occupations, marital status, health care insurance
biographical info
42
you learn the patients concerns or problems
chief concern
43
find out what patients expect to happen to them while seeking treatments
patient expectations
44
determine when the problems began, how severe, intensity, quality, what makes it worse or better
present illness or health concerns
45
what is PQRST
provokes, quality, radiates, severity, time
46
provides you with info regarding the patients past history. family history data about immediate and blood relatives which determines risks of genetic or familial nature
health history
47
home environment workplace environment or exposure to pollutants
environmental history
48
support system, spouse, children, friends
psychosocial history
49
review with patients their beliefs about life, their source for guidance. also assess rituals and religious practices that patients use to express their spirituality
spiritual health
50
a systemic approach for collecting subjective info from patients about problems in each body system
review of systems
51
nursing health history includes
-biographical info
cheif concerns
present illness
health history
environmental history
psychosocial history
spiritual health
review of systems
diagnostic and lab data
interpreting and validating assessment data
52
interpreting and validating assessment data leads to what
second step of nursing process
53
data validation includes validating a patients report with what
a nursing observation or assessment
54
data validation can lead you to do what if you find something that does not go with the patient
reassess or gather additional info
55
Which scenario best illustrates the nurse using data validation when making a nursing clinical decision for a patient?
The nurse determines to remove a wound dressing when the patient reveals the time of the last dressing change and notices old and new drainage.
The nurse administers pain medicine due at 1700 at 1600 because the patient reports increased pain and the family wants something done.
The nurse immediately asks the health care provider for an order of potassium when a patient reports leg cramps.
The nurse elevates a leg cast when the patient reports decreased mobility.
A
56
what becomes the baseline for care
data documentation
57
what is a visual representation that allows you to graphically show the connections among a patients many health problems
concept mapping
58
it is important to closely observe a patients verbal and nonverbal behaviors to what
determine if they match what the chart says
59
observations direct you to gather additional objective information to form what
accurate conclusions about the patients condition
60
an important aspect of observation includes a patients level of function which includes
-the physical, developmental, psychological, social aspects of everyday living
61
the protecting, promotion and optimilization of health and abilites
how ANA defines nursing
62
part of the nursing process that determines your patients main problem
diagnosis
63
how do you gather nursing diagnosis
from clinical judgement
64
FOCUS ON __________ AND ILLNESS AND INJURY AND ALLEVAITION OF SUFFERING THROUGH DIAGNOSIS OF HUMAN RESPONSE AND _________ FOR THE CARE OF INDIVUDUALS FAMILIES COMMUNITIES AND POPULATIONS
-prevention
-advocating
65
what is the difference between medical diagnosis and nursing diagnosis
medical diagnosis deals with disease or medical condition and a nursing diagnosis deals with human response to actual or potential health problems and the life process
66
a collaborative problem will require what two things
nursing diagnosis and medication
67
3 types of problems for a nursing diagnosis
-focused problem
-risk for a problem
-health promotion
68
what should a nursing diagnosis include
problem
etiology
symptoms
69
This provides direction for individualized care of the client
a care plan
70
the care plan flows from each patients unique ________ and is organized by the patients ________
-assessment
-specific needs
71
in the care plan, as needs are met what happens to the care plan
it is updated
72
when is the nursing care plan done?
when the patient is admitted
73
how long will the actions of the care plan be done?
as long as the patient is admitted
74
components of a care plan
-client database
-interviewing
-physical assessment
-diagnostic studies
75
the nurse must complete a thorough _______ of client and their problems to create a care plan
assessment
76
use _______ to provide what actions you will do and not do for specific patients
critical thinking
77
pieces of a care plan
-diagnosis
-outcome/goal
-intervention
78
what is the area of concern that nurses can treat/prevent/monitor of the care plan
diagnosis
79
what is the appropriate goal for this patient part of the care plan
-outcome/goal
80
what treatment is most effective part of the care plan
-intervention
81
identifying the problem or need of specific patient
diagnosis
82
a result of an achievable nursing intervention and client response
outcome/goal
83
how can the nurse interject to achieve the expected outcome
intervention
84
what do we use to create a nursing diagnosis for our patient
data collection
85
a clinical judgement about actual or potential individual, family, or community experiences
a nursing diagnosis
86
a nursing diagnosis can also be an individuals response to ________ or __________
-health problems
-life processes
87
a nursing diagnosis is used to define the right place of care for the client and drives ______ and patient _______
-interventions
-outcomes
88
nursing diagnosis allow for ________ among the care team members
clear communication
89
nursing diagnosis will be out ______ about patient family or community
clinical judgement
90
a nursing diagnosis has a more ______ understanding of the impact of a condition on a particular patient and his/her family than a medical diagnosis
holistic
91
what provides info that gives all members of the health care team a common language for understanding patients needs
nursing diagnosis
92
what does nanda stand for
north american nursing diagnosis organization international
93
what is the professional organization of nurses involved in creating approved standardized nursing diagnoses
nanda-i
94
the _______ process requires you to use critical thinking
diagnostic
95
the diagnostic reasoning process involves using the ________ data gathered about a patient to logically explain a clinical judgement or a nursing diagnosis
assessment
96
what are the three types of nanda-i diagnoses
actual problem focused nursing diagnosis
risk nursing diagnosis
health promotion nursing diagnosis
97
describes human responses to health conditions or life processes
actual (problem focused) nursing diagnosis
98
describes human responses to health conditions/life processes that may develop in a vulnerable individual
risk nursing diagnosis
99
a clinical judgement of motivation, desire, and readiness to enhance well-being and actualize human health potential
health promotion nursing diagnosis
100
what do you need for an actual (problem focused) nursing diagnosis
-problem
-etiology
-signs and symptoms
101
what is the format for an actual nursing diagnosis
problem related to what is causing the problem as evidence by signs and symptoms
102
what is used for a risk for nursing diagnosis
potential problem
signs and symptoms
103
what is not used for a risk for nursing diagnosis and why
no etiology because this is not an actual problem yet
104
what is the format for a risk for nursing diagnosis
potential problem as evidence by three signs and symptoms
105
what is included in a readiness for nursing diagnosis
-potential health promotion
-signs and symptoms
106
what is different about a readiness for diagnosis than the other two?
the patient is wanting to make a change
107
what is the format for a readiness for nursing diagnosis
health promotion (readiness for) _____ as evidence by 3 signs and symptoms including desire on patients part
108
common nanda-i nursing diagnoses
-acute pain
-activity intolerance
-anxiety
-impaired gas exchanged
-impaired skin integrity
-impaired physical mobility
-decreased cardiac output
-deficient fluid volume
109
how do you prioritize nursing diagnoses
-abc's first
-maslows second
110
which diagnoses are not a priority
risk diagnoses
111
which are the most important things to remember on maslows chart
-breathing
-food
-water
-sex
-sleep
-homeostasis
-excretion
112
what are the five levels of maslows bottom to top
-physiological
-safety
-love/belonging
-esteem
-self-actualization
113
classification of priorities
high - emergent life threatening
intermediate - non life threatening
low - affect patients future well-being
114
what are considered low priority for diagnosis
risk for and health promotion
115
what should always come first when making a nursing diagnosis
the patients current problem or anything life threatening
116
if the patient has any changes in their presentation first _______ then _______
assess
determine nursing diagnosis for new assessment and plan for new goal and interventions
117
nursing is both a ______ and ________
-art
-science
118
primary goal of nursing is to what
respond to the needs of patients
119
science in nursing is what
evidenced based practice and a body of knowledge that is always changing
120
knowledge of this history of the nursing profession increases your ability to understand the _____ and ______ origins of the discipline
-social
-intellectual
121
who is the mother of modern nursing
florence nightingale
122
florence nightingale was the first practicing what
epidemiologist
123
what did florence organize
first school of nursing
124
what did florence improve
sanitation in battlefield hospitals
125
what is florence known as
lady with the lamp
126
florence ______ information and kept record on ________ and the effects on health
collected
sanitation
127
what did florence take into consideration
the patient, the patients environment and how it affected the patient
128
florence's practices remain what
a basic part of nursing today
129
who was the founder of the red cross
clara barton
130
who organized ambulance services
mother bickerdyke
131
who walked battlefield at night looking for wounded soldiers
mother bickerdyke
132
who was the prominent female in the underground railroad movement and helped free slaves
harriet tubman
133
who was the first professionally trained african american nurse
mary mahoney
134
who brough forth awareness of cultural diversity
mary mahoney
135
who opened the henry street settlement
lilliam walk and mary brewster
136
lillian wald and mary brewster worked in henry street settlement and were some of the first to demonstrate what
autonomy in their practice
137
when did nurses assume advanced practice roles
20th century
138
what else happened in the 20th century
a movement toward developing a scientific, research-based practice and defined body of knowledge
139
when did changes in nursing school curriculum occur
21st century
140
what changes happened with nursing in the 21st century
-changes in nursing school curriculum
-advances in technology and informatics
-new programs address current health concerns
-nursing is taking a leadership role in developing standards and policies
141
new programs address current health concerns and focus on what
-supporting nursing scholars
-decreasing the nursing shortage
-improving the health of the nations population
142
a type of burnout that can affect quaility of care, and the health and wellness of nurses
compassion fatigue
143
current influences on nursing
-human rights
-affordable care act
-rising health care costs
-demographic changes
-medically underserved
144
the right to health and right to think
human rights
145
presents challenges to the nursing profession, consumer, and health care delivery system
rising health care costs
146
movement of people from rural to urban areas, increased life span, increases in patients living with chronic and long term illnesses
demographic changes
147
people on unemployment, have low paying jobs, mental illnesses and are homeless
medically underserved
148
affects how health care is paid for and delivered more nursing in community based settings
affordable care act
149
nursing requires what three things
-current knowledge and practice standards
-insightful and compassionate standards
-critical thinking
150
benners stages of nursing proficiency
-novice
-advanced beginner
-competent
-proficient
-expert
151
nursing students, nurse entering a position with no experience
novice
152
some level of experience as a nurse
advanced beginner
153
2-3 years of the same clinical experience
competent
154
more than 2-3 years of experience in the same clinical position
proficient
155
diverse experience take time and commitment to become an expert 10 years
expert
156
what type of nurse is focused on managing care vs performing skills
proficient
157
what is the goal of nursing
to improve the health and well-being of all individuals communites and populations through the significant and visible contributions of registered nursing using standards-based practice
158
ANA six standards of practice
-assessment
-diagnosis
-outcomes identification
-planning
-implementation
-evaluation
159
what is the foundation of clinical decision making
the nursing process
160
initiation of nursing interventions without medical orders
-autonomy
161
responsible profession as well as legally for the quaility of care we deliver making sure we are providing competent nursing care
accountability
162
meet or maintain health, regain health and find maximum level of independence through the healing process includes patients emotional, social and spiritual wellbeing
caregiver
163
protect our patients human and legal rights and also helping them asserting their rights like making sure they understand a procedure
advocate
164
teach patients about their health and how to manage it provide teaching in a level they can understand
educator
165
essential part of nursing to gain trust with patient and effective communication with healthcare team
communicator
166
coordinate activities and safe and quality care
manager
167
roles and responsibilities of nursing profession
-autonomy
-accountability
-caregiver
-educator
-manager
-advocate
-communicator
168
essential nursing skills include:
-time management
-therapeutic communication
-patient education
-compassionate implementation of bedside skills
169
registered nurse education types
-two year associates degree
-four year baccalaureate degree
170
graduate nursing education
-masters degree
-advanced practice RN
-doctoral degrees
171
what is the most common form of continuing knowledge for nurses
-continuing education (CEUs)
-in service education
172
how many hours in a two year period do nurses need of continuing education courses to keep license
typically 30 hours
173
advanced practice registered nurses
-clinical nurse specialist
-certified nurse practitioner
-certified nurse midwife
-certified registered nurse anesthetist
174
additional career development for nurses
-advanced practice registered nurses
-nurse educator
-nurse administrator
-nurse researcher
175
who are nurse practice acts overseen by
state boards of nursing
176
what regulates scope of nursing practice
-nurse practice acts
177
nurse practice acts protect public ______, ______ and _____
-health
-safety
-welfare
178
what do professional nursing organizations do
-address member concerns
-present educational programs
-publish journals
179
professional nursing organizations include
-national league for nursing
-american nurses association
-international council of nursing
180
student organizations
national student nurses association
181
what lead to changes in nursing
-increased technology
-new demographic patterns
-consumerism
-health promotion
-womens and humans rights movements
182
what provides the guidelines for implementing and evaluating nursing care
nursing standards
