Nursing 101 exam 2 Flashcards
What is the Nursing Process? (the 5 parts)
- assess
- (nursing) diagnoses
- planning and outcome identification
- implement
- evaluate
List the 5 characteristics of the Nursing Process
- Systematic
(part of an ordered sequence of activities)
- Dynamic
(great interacting and overlap among the 5 steps)
- Interpersonal
(human being at the heart of nursing)
- Outcome oriented
(nurses and patients work together)
- Universally Applicable
(a framework for all nursing activities)
Give 3 potential errors in decision making
*Bias
* Failure to consider the total situation
* Impatience
List the 7 characteristics of nursing Assessment
- purposeful
- prioritized
- complete
- systematic
- accurate
- relevant
- recorded in a standard manner
List the four different types of nursing assessment
which of the four nursing assessment types deals with
- getting info for a specific problem already identified or to identify new or overlooked problems
- happens during initial assessment or as routine ongoing data collection
- performed by a nurse to collect data about a specific problem
Focused Assessment
Which of the 4 types of nursing assessment types is
- performed to identify life threatening problems
- performed when a physiologic or psychological crisis occurs
- performed by a nurse to gather data about a life threatening problem
Emergency Assessment
Which of the 4 types of nursing assessments is
- performed shortly after admittance to the hospital or service
- performed to establish a complete database for problem identification and care planning
- performed by the nurse to collect data on all aspects of patients health
Initial Comprehensive Assessment
Which of the 4 nursing assessment types is
- performed to compare a patient’s current status to baseline data obtained earlier
- to reassess health stautus and make necessary revisions in plan of care
- performed by the nurse to collect data about current health status of patient
Time-Lapsed Assessment
What is the focus of Medical Assessments and what is the focus of Nursing Assessments?
Medical Assessments: target data to help identify disease
Nursing Assessment: focus on patients response to health problems; clinical judgment
What is the difference between subjective data and objective data?
Subjective data: what the patient says they are feeling; you can’t see subjective (I feel tired, I have a headache)
Objective data: what you can observe, scientific data, visual
(vital signs, sweat, vomit, shivering, etc.)
List five different sources (ways to obtain) a patients data
- patient
- family/significant others
- patient record
- medical history
- lab reports/ other diagnostic studies
- reports of therapy from other healthcare pros
What is the purpose of nursing observation?
(what are you learning about the patient?)
to get the patients..
- current responses (physical and emotional)
- current ability to manage care
- determines the immediate environment and it’s safety
- determines the larger environment (hospital or community)
What are these 4 phases referring to?
- preparatory phase
- Introduction
- Working phase
- Termination
The 4 phases of the nursing interview
What is the purpose of doing a nursing physical assessment?
(3 reasons)
- Appraisal of health status
- Identify health problems
- establish a database for nursing intervention
When does data need to be validated?
When there’s a discrepancy between what the person is saying and what the nurse is observing.
When the data lacks objectivity
What is concept mapping?
a strategy where learners identify, link, and display key concepts.
cognitive tools for learning that promote critical thinking and self-directed learning
also called cognitive maps and mind maps
List some ways to verify and validate data
- physical exam using proper equipment and procedure
- use clarifying statements
- share inferences with other team members
Referring to Maslow’s Hierarchy of needs, what does Maslow say is the first two things you need before you can have anything else?
- Physiological (basic needs)
(air, food,water, sleep, homeostasis, excretion)
- safety
(security of body, morality, health)
What is the specific type of practice that is a purposeful activity that leads to action, improvement of practice, and better patient outcomes?
(it’s about looking at an event, understanding it, and learning from it)
Reflective practice
Describe the term Nursing Diagnoses
Actual or potential health problems that can be prevented or resolved by independent nursing intervention.
The nurse formulates, validates, and lists nursing diagnoses for each patient.
What does Alfaro recommend using to organize assessment data to detect both nursing and medical problems?
he recommends using both a nursing model and a body systems approach
The term nursing diagnoses first appeared in literature in the 1950’s. Hammond wrote that nurses need to be what?
Hammond wrote that nurses need to have a good background of what?
nurses need to be competant in information seeking strategies and should have a good background of theoretical knowledge to search for cues and evaluate evidence.
What do you call a condition that necessitates intervention to prevent or resolve disease or illness or to promote coping and wellness
A health problem
Nursing diagnoses are written to describe patient problems or issues that nurses can treat independently, such as ________, pain and comfort, and ______ integrity and perfusion problems
activity
tissue integrity
Nursing diagnoses focus on unhealthy response to health and illness, whereas Medical Diagnoses ________ ________
identify diseases
Medical diagnoses describe problems for which the physician directs the primary treatment, whereas nursing diagnoses describe problems treated by nurses within the scope of ____________ _______ ________
independent nursing practice
A Nursing Diagnosis may change from day to day as the patient’s responses change, whereas as a Medical diagnosis……….
remains the same for as long as the disease is present
Myocardial Infarction (heart attack) is a Medical Diagnosis. Examples of Nursing Diagnoses for a person with Myocardial Infarction may include Fear, Altered Health Maintenance, Deficient Knowledge, Pain, and altered Tissue Perfusion.
true or false?
true
What are Collaborative Problems?
(according to Carpenito)
Certain physiologic complications that Nurses monitor to detect onset or changes in status.
Are Collaborative Problems a type of diagnoses?
yes
How are Collaborative Problems managed?
by using physician-prescribed and nursing-prescribed interventions
When a Nurse writes patient outcomes that require delegated medical orders for goal achievement, is this situation considered a Nursing Diagnosis or a Collaborative Problem?
Collaborative Problem
A helpful way to remember the difference between nursing diagnoses and collaborative problems is to connect the “ C’s “.
what does that mean?
Collaborative equals Complications
If you were going to write a diagnostic statement for a collaborative problem, what would you be focused on writing about?
potential complications of the problem
(PC)
