NURS 175- Midterm II Flashcards
What are the Six Phases of Assessment in the Nursing Process?
- Collect data
- Identify cues and make inferences about data
- Validate/verify data by checking with the patient
- Cluster data
- Identify patterns
- Report and record data
What are the four different ways you can cluster data?
- Categories based on body systems
- Health patterns (e.g. nutrition, elimination, activity etc.)
- Functional approach ( cues, inference, category)
- Human needs approach (Maslow’s)
What is a Nursing Diagnosis?
a clinical judgement that provides the basis for nursing interventions using common nomenclature
What is the difference between a nursing diagnosis and a medical diagnosis?
Nursing- focused on human response to health problems
Medical- focus is on disease
What is NANDA and in what stage of the Nursing Process is it used?
North American Nursing Diagnosis Association
- diagnosis
What are the four steps of forming a diagnosis?
- Consider assessment data, cues, clusters, analysis
- Choose NANDA label
- Determine etiology
- List the manifestations (sings/symptoms)
A “Risk For” diagnosing label indicates that…
there is no manifestation or evidence to identify the health problem
How should you prioritize nursing diagnoses?
- Maslow’s
- Actual before potential
What is a potential diagnosis?
problem/situation that could be prevented
What is an actual diagnosis?
actual problem has been identified and nursing process should include all three parts
What is a syndrome diagnosis?
a short cut to describe a pattern of signs and symptoms that form a distinct clinical disorder
-groups several other NANDA diagnoses together
What is a wellness diagnosis?
used for patients who are already healthy but want to maintain or improve their wellness level
When does the planning stage begin and end?
The planning stage begins upon introduction to your patient/family and ends upon discharge/transfer/death
What are the three types of planning?
- Initial- admission assessment; directs patient care
- Ongoing- continually changing plans based on patient response
- Discharge- anticipates and plans for when patient moves on
____ can be used to help make outcomes specific.
scales
What is NOC, and in what stage of the nursing process is it used?
- Nursing Outcomes Classification
- Canadian nurses mostly create their own outcome statements
- planning stage
What does SMART stand for?
S- Specific to your patient M- measurable A- achievable R- realistic T- timed (deadline)
What is an Independent Nursing Intervention?
an intervention a nurse can accomplish without and order
What is a Dependent Nursing Intervention?
initiated by physician’s order
What is a Collaborative Nursing intervention?
nurse and other health care professional collaborate but usually the nurse completes them
Nursing interventions are based…
the outcome statement
What is NIC, and in what step of the nursing process does it belong?
- Nursing Intervention Classification
- research based
- always used in practice
- planning
Describe the implementation stage of the nursing process
- prioritize interventions
- work towards established goals
What is the difference between direct and indirect care?
Direct- ADLs, physical care, etc.
indirect- communicating interventions, evaluating work of others, delegating, supervising etc
Describe the evaluation stage of the nursing process
- determines effectiveness of interventions
- reviews whether goals were met
- sometimes re-evaluating occurs
What are the three possible determinations of evaluation?
- Goal met
- Goal partially met
- Goal not met
What are the six factors that are required for quality of care?
- Accessibility- right care, right practitioner, right factor
- Effectiveness- based on scientific evidence
3 . Efficiency- not wasting time, supplies, expertise - Patient Safety- everything we do is to reduce harm to our patient
- Patient - Centered Care
- Equitable- everyone gets the same access and treatment availability; people who need extra help get extra support
What is required for something to be an accident? What does this mean for accidents in healthcare?
- must be unavoidable
- they happen very little in healthcare
Patient safety is the _______ of unsafe acts through the use of _____ with the goal of _______.
- reduction and mitigation
- best practices
- optimal patient outcomes
What are the five factors that effect patient safety?
- Health Care Provider/Patient Factors
- Task Factors
- Technology Factors
- Environmental Factors
- Organizational Factors
To which patient safety factor does CARNA belong?
environmental
What is the CPSI and what is it’s goal?
- Canadian Patient Safety Institute
- multidisciplinary approach to safe patient care
What re the six CPSI safety framework domains?
- Contribute to a culture of patient safety
- Work in teams for patient safety
- Communicate effectively for patient safety
- Manage safety risks
- Optimize human and environmental factors
- Recognize, respond to, and disclose adverse events
What are the differences between a harmful incident, a near miss, and no harm incident?
- harmful incident- results in patient harm
- near miss- incident that did not reach the patient
- no harm- reached the patient but no discernible harm occurred
Describe the Swiss Cheese Conceptual Model
- about safety
- “sometimes all the holes line up”
- system is the focus
Describe the Iceberg Conceptual Model
- root cause analysis
- look beyond surface
- looks at contributing factors
Explain the purpose of disseminating the learning lesson
- everyone learns from the mistake
- less about individual blame, more about learning from mistakes
What is the difference between infant and adolescent developmental risk factors?
- infants- don’t realize certain things are risks
- adolescents- revolve around risk taking behaviours
What are the three steps to take if an event occurs?
- Disclosure (how it was handled, future plans to minimize the chance of reoccurrence, regret event occurred)
- Anticipate the patient/family’s reaction
- Plan for support if needed
Incident reports should be made to _____ (RLS) including_____.
- reporting and learning system
- near misses
Name some if the most common types of errors
- medication
- transfusion
- surgeries
- restraints
- falls
- burns
- pressure injuries
- wrong patient
