Nursing Health Saftey Flashcards
The American Nursing Associations defines the nursing process as an ongoing and systematic cycle comprised of the following 6 sequential steps:
Assessments Diagnosis Outcomes identification Planning Implementation Evaluation
Excelsior college teaches the nursing process as 5 sequential steps. What are they?
Assessment Analysis Planning Implementation Evaluation
Standard 1: Assessment refers to what?
A systematic and ongoing collection of data relevant to a pt’s health or to the situation or ambience influencing a pt’s health.
Standard 2: Diagnosis definition (ANA)?
The clinical judgement about the healthcare consumers response to actual or potential health conditions or needs.
Standard 3: Outcomes identification (ANA)?
Refers to the identification of expected care outcomes that are individualized according to the pt’s presenting needs or diagnosis to the situation in which the pt. is found.
Standard 4: Planning (ANA)?
Developing a plan of care and prescribes strategies designed to achieve the expected outcomes.
Standard 5: Implementation (ANA)?
May include any or all of activities such as: providing, monitoring, delegating, coordinating, teaching, and counseling.
Standard 6: Evaluation (ANA)?
The process of determining the progress toward attainment of expected outcomes, including the effectiveness of care.
What are the 5 components of a nursing diagnosis?
1) diagnostic label
2) definition of the diagnosis
3) defining characteristics of a diagnosis
4) risk factors associated with the diagnosis
5) other factors related to the diagnosis
What are the 5 types of nursing diagnosis?
1) actual diagnosis
2) health promotion diagnosis
3) risk diagnosis
4) syndrome diagnosis
5) possible diagnosis
What are the NANDA-1 axes identified? There are 7 of them.
1) the diagnostic focus
2) subject of the diagnosis
3) judgment
4) location
5) age
6) time
7) status of the diagnosis
What are the 4 main care plan components?
EASE!
E - expected outcomes
A - Actual & potential problems
S - specific interventions
E - Evaluation / Progress notes
What are the 5 components of outcome statements?
Subject: Who is the person expected to achieve the outcome (e.g., patient or parent)?
- Verb: What actions must the person take to achieve the outcome?
- Condition: Under what circumstances is the person to perform the actions?
- Performance criteria: How well is the person to perform the actions?
- Target time: By when is the person expected to be able to perform the actions?
Example: “Parents will bathe newborn in room independently by 5/8.”
Regarding Standard 5 of the Nursing Process, Implementation, what are the subcategories?
5A) Coordination of care
5B) Health teaching and health promotion
Regarding Problem-Oriented Medical Record (POMR), what are the 4 basic components? Describe?
1) database - pt’s info
2) problem list - as described
3) plan of care - care plan
4) progress notes - soap format frequently used, as well as soap-ier (interventions, evaluations, revision)
What is the PIE documentation model groups information into three categories?
PIE is an acronym for Problems, Interventions, and Evaluation of nursing care. They can also have numbers added, for instance, problem #5, or intervention #3.
If there is no approved nursing diagnosis for a problem, the nurse develops a problem statement using NANDA’s three-part format: client’s response, contributing or probable causes of the response, and characteristics manifested by the client.
What is focused charting?
Focus Charting - Focus charting is intended to make the client and client concerns and strengths the focus of care.
The progress notes are organized into (D) data, (A) action, and (R) response, referred to as DAR.
What is Charting by exception?
Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.
CBE incorporates three key elements: flowsheets, standards of nursing care, & bedside access to chart forms.
What does ISBAR stand for regarding handoff communication tools?
I-SBAR: Introduction, Situation, Background, Assessment, Recommendation.
List the five functions of the initial comprehensive nursing assessment.
a. Make a judgment about a patient’s health status.
b. Make a judgment about a patient’s ability to manage his/her own healthcare.
c. Make a judgment about a patient’s need for nursing.
d. Refer the patient to a physician or other healthcare professional.
e. Plan & deliver individualized, holistic nursing care that draws on the patient’s strengths
Identify eight sources of patient data, & give an example of each.
a. Patient: Most patients are willing to share information when they know it is helpful in planning their care.
b. Support people: Family members, friends, & care-givers are helpful sources of data when a patient is a child or has a limited capacity to share information with the nurse.
c. Patient record: A review of the records prepared by different members of the healthcare team provides information essential to comprehensive nursing care.
d. Medical history, physical examination, & progress notes: Sources that record the findings of physicians as they assess & treat the patient.
e. Reports of laboratory & other diagnostic studies:
These sources (e.g., x-rays & diagnostic tests) can either confirm or conflict with data collected during the nursing history or examination.
210 f. Reports of therapies by other healthcare professionals: Other healthcare professionals record their findings & note progress in specific areas (e.g., nutrition, physical therapy, or speech therapy).
g. Other healthcare professionals: Other nurses, physicians, social workers, etc., can provide information about a patient’s normal health habits & patterns & response to illness.
h. Nursing & other healthcare literature: If a nurse is unfamiliar with a disease, it is important for him/her to read about the clinical manifestations of the disease & its usual progression to know what to look for when assessing the patient
Briefly describe why the following characteristics of data are important when collecting & recording patient data.
a. Purposeful: ___________________________________________________________________________
b. Complete: ___________________________________________________________________________
c. Factual & accurate: __________________________________________________________________
d. Relevant: _____________________________________________________________________________
a. Purposeful: the nurse must identify the purpose of the nursing assessment (comprehensive, focused, emergency, time-lapsed) & then gather the appropriate data.
b. Complete: All patient data need to be identified to understand a patient’s health problem & develop a plan of care to maximize health promotion.
c. Factual & accurate: Nurses concerned with accuracy & fact must continually verify what they hear with what they observe using other senses & validate all questionable data.
d. Relevant: Because recording data can become an endless task, nurses must determine what type of data & how much data to collect for each patient.
Give an example of three observations nurses should make each time they encounter a patient.
a. What are the patient’s current responses to his/her situation?
b. What is the patient’s current ability to manage his/her care?
c. What is the immediate environment?
List three patient goals that should be accomplished by the end of the introduction phase of the patient interview.
a. Patient should know the name of his/her primary nurse & what he/she can expect of nursing.
b. Patient should sense that the nurse is competent & cares about him/her.
c. Patient should know what is expected of him/her in terms of developing the plan of care & participating in its execution.
