NUR300 topic 4

Question 1

Steps of nursing process and application to nurse

Answer 1

• is a critical thinking 5 step process that professional nurses use to apply the best available evident to caregiving and promoting human functions and responses to health and illness.
• ADPIE (Assessment, diagnosis, planning, implementation, and evaluation)

Question 2

Identify the role of NANDA-I and nursing diagnoses in the provision of client care

Answer 2

• North American Diagnosis Association International
• list contains several hundred diagnoses and continues to grow on the basis of nursing research and the work of the NANDA-I
• Diagnosis include: Problem focused, risk, and health promotion

Question 3

Problem focused nursing diagnosis (NANDA)

Answer 3

describes the clinical judgement concerning an undesirable human response to a health condition/life process that exists in an individual, family or community

Question 4

risk nursing diagnosis (NANDA)

Answer 4

is a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes

Question 5

Health promotion nursing diagnosis

Answer 5

is a clinical judgment concerning a patient’s motivation and desire to increase well being and actualize human health potential

Question 6

Diagnostic label for NANDA

Answer 6

• is the name of nursing diagnosis approved by NANDA

- PES: problem, etiology or related to, symptoms or defining characteristics

Question 7

Critical thinking approach to nursing assessment

Answer 7

-Collection of info from a primary source (patient) and secondary sources (family, friends, health professionals, the medical record)
-the interpretation and validation of data to ensure a complete database
critical thinking and the assessment process: knowledge, standards, attitudes, experience affect the nursing process (ADPIE)

Question 8

different assessments

Answer 8

patient centered interview during a nursing health history, a physical exam, periodic assessments you make during rounding or administrating care

Question 9

components of health history

Answer 9

biographical data
chief concern or reason for seeking care
patient expectations
present illness or health concerns
health history
family history
psychosocial history
spiritual health
review of systems

Question 10

critical thinking

Answer 10

setting goals and expected outcomes

Question 11

patient centered goal

Answer 11

reflects a patient’s highest possible level of wellness and independence in function

Question 12

goals need to be:

Answer 12

specific, measurable, attainable, realistic, and timed

Question 13

Nursing interventions

Answer 13

• independent: nurse initiated, actions that the nurse initiates w/o supervision or direction from other
• dependent: health care provider, actions that require an order from a healthcare provider
• collaborative: or independent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care providers

Question 14

direct care vs. indirect care

Answer 14

• direct: treatments performed through interactions w/ patients
• indirect: interventions are the treatments performed away from a patient but on behalf of the patient or group
• direct care: ADLs, IADLs, physical care techniques, lifesaving measures, counseling, teaching, controlling for adverse reactions, and preventing measures