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FOUNDATIONS 310 > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

4 skills necessary to performs the nursing process

A
  1. critical thinking
  2. critical reasoning (evidence based practice)
  3. communication
  4. concept based learning
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2
Q

6 phases of nursing process

A
  1. assessment
  2. diagnosis
  3. outcome
  4. planning
  5. implementation
  6. evaluation
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3
Q

What happens during assessment phase?

A
  • collection of subjective and objective data
  • holistic
  • information gathered about past and present
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4
Q

Primary Source in assessment

A

Patient

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5
Q

Secondary sources in assessment

A

-labs, diagnostic tests, report from someone else (family)

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6
Q

How do you collect subjective data?

A

Interview

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7
Q

techniques of inspection (palpation, percussion, auscultation)- objective or subjective data?

A

objective

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8
Q

measurement devices- - objective or subjective data?

A

objective

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9
Q

health record- objective or subjective data?

A

objective

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10
Q

laboratory studies/xray/labs/diagnostic procedures - objective or subjective data?

A

objective

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11
Q

symptoms - objective or subjective data?

A

objective

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12
Q

signs- objective or subjective data?

A

objective

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13
Q

feelings/attitudes- objective or subjective data?

A

subjective

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14
Q

values/beliefs- - objective or subjective data?

A

subjective

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15
Q

what happens in an admission assessment?

A
  • health history
  • head to toe physical exam
  • functional status, collection of data concerning actual or potential dysfunction baseline for reference and future comparison
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16
Q

when does a focus assessment occur and what is it?

A
  • status determination of a specific problem identified during previous assessment
  • a few minutes to hours between assessments
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17
Q

What is a time-lapse reassessment?

A

-detection of changes in all functional asreas after an extended period of time has passed

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18
Q

How often does time lapse reassessment occur?

A

several months (3-9) between assessments

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19
Q

What is an emergency assessment?

A

-identification of life threatening physical or psychological emergency

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20
Q

The act of noticing patient cue

A

Observation

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21
Q

Interaction and communication process for gathering data by questioning and information exchange

A

interviewing

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22
Q

analysis of bodily functioning using the techniques of inspection, palpation, percussion, and auscultation

A

physical examination

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23
Q

4 parts of interviewing

A
  1. preparatory phase
  2. introductory phase
  3. maintenance phase
  4. concluding phase
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24
Q

What happens in preparatory phase?

A
  • phase 1 of interview
  • gather all pertinent information
  • determine what info you want
  • set the environment
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25
Q

What happens in introductory phase of interview?

A

phase 2 of interview

-identify self, what you are doing, and how long you are doing it

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26
Q

When does introductory phase occur? (frequency)

A

every time you go in patient room

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27
Q

What happens in maintenance phase?

A

Phase 3 oh interview process

  • facilitate dialogue
  • answer questions
  • focus on task
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28
Q

What happens with concluding phase?

A

phase 4 of interview

  • review goal or task attainment
  • summarize highlights
  • encourage questions
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29
Q

4 steps of the physical assessment

A
  1. inspection
  2. palpation
  3. percussion
  4. auscultation
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30
Q

Part of the physical assessment that is a visual assessment

A

Inspection

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31
Q

Part of the physical assessment using touch to determine size, shape and configuration of underlying body structures

A

palpation

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32
Q

Part of physical assessment with use of sounds from tapping areas on the body to determine underlying body structure

A

percussion

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33
Q

part of physical assessment using a stethoscope to amplify sound

A

auscultation

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34
Q

What happens in the diagnosis phase of the nursing process?

A
  • phase 2
  • human responses to actual or potential healthcare problems
  • derived from the assessment data
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35
Q

Is the nursing diagnosis the same as a medical diagnosis?

A

No

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36
Q

What institution develops nursing diagnoses

A

North American Nursing Diagnosis Association (NANDA)

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37
Q

4 components of nursing diagnosis

A

(2nd step in nursing process)

  1. diagnostic label
  2. related factors
  3. Defining characteristics
  4. Risk factors
38
Q

What is the diagnostic label? example?

A
  • first part of nursing diagnosis
  • something the patient has
    ex: deficient knowledge, impaired urinary elim, risk for infection
39
Q

What is related factors part of nursing diagnosis?

A
  • 2nd part

- medical conditions or circumstances that relate to the problem but do not directly cause it

40
Q

What is the defining characteristic part of nursing diagonsis?

A
  • part 3
  • observable cues that support diagnosis
  • signs and symptoms
41
Q

what is the risk factor part of nursing diagnosis?

A
  • used in “risk for” diagnosis only**

- elements that could cause the problem

42
Q

3 part nursing diagnosis has..

A
  • diagnostic label
  • related factors
  • defining characteristics
43
Q

2 part nursing diagnosis

A
  • diagnostic label

- risk factors

44
Q

PES format for nursing diagnosis

A

Problem (diagnostic label)
Etiology (related factors)
Signs/symptoms (defining characteristic)

45
Q

Outcomes need to be…

A
  • measurable
  • realistic
  • patient- focused
    aka: goals
46
Q

The development of a care plan to address the outcomes

47
Q

What is required for outcome identification?

A

prioritization

48
Q

How do you determine priority?

A
  • urgency

- importance

49
Q

After something life threatening what is the next priority?

A

-pain management

50
Q

What is a nursing intervention?

A

any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes

51
Q

Types of nursing interventions…

A
  • psychomotor
  • psychosocial
  • educational
  • maintenance
  • surveillance
  • supervisory
  • sociocultural
52
Q

Cognitive, interpersonal or technical nursing intervention:

Teach/educate

53
Q

Cognitive, interpersonal or technical nursing intervention:

Relate knowledge to ADLS

54
Q

Cognitive, interpersonal or technical nursing intervention:

Provide Feedback

55
Q

Cognitive, interpersonal or technical nursing intervention:

Create strategies for patients with dysfunctional communication

56
Q

Cognitive, interpersonal or technical nursing intervention:

Delegate to UAP

57
Q

Cognitive, interpersonal or technical nursing intervention:

Supervising nursing team, patient or family in performance

58
Q

Cognitive, interpersonal or technical nursing intervention:

Alter environment as needed

59
Q

Cognitive, interpersonal or technical nursing intervention:

Coordinate activities

A

interpersonal

60
Q

Cognitive, interpersonal or technical nursing intervention:

Provide caregiving

A

interpersonal

61
Q

Cognitive, interpersonal or technical nursing intervention:

use of therapeutic communication

A

interpersonal

62
Q

Cognitive, interpersonal or technical nursing intervention:

provide a personal presence

A

interpersonal

63
Q

Cognitive, interpersonal or technical nursing intervention:

set limits

A

interpersonal

64
Q

Cognitive, interpersonal or technical nursing intervention:

provide opportunity to examine values and attitudes

A

interpersonal

65
Q

Cognitive, interpersonal or technical nursing intervention:

explore and legitimize feelings

A

interpersonal

66
Q

Cognitive, interpersonal or technical nursing intervention:

Provide spiritual support

A

interpersonal

67
Q

Cognitive, interpersonal or technical nursing intervention:

use humor

A

interpersonal

68
Q

Cognitive, interpersonal or technical nursing intervention:

provide individual or group therapy

A

interpersonal

69
Q

Cognitive, interpersonal or technical nursing intervention:

be patient advocate

A

interpersonal

70
Q

Cognitive, interpersonal or technical nursing intervention:”

make referrals and follow ups

A

interpersonal

71
Q

Cognitive, interpersonal or technical nursing intervention:

serve as role model

A

interpersonal

72
Q

Cognitive, interpersonal or technical nursing intervention:

support patient and family plans

A

interpersonal

73
Q

Cognitive, interpersonal or technical nursing intervention:

provide basic hygeine and skin care

74
Q

Cognitive, interpersonal or technical nursing intervention:

perform routine nursing activities

75
Q

Cognitive, interpersonal or technical nursing intervention:

detect change from baseline, reorganize abnormal responses

76
Q

Cognitive, interpersonal or technical nursing intervention:

assist with ADLS

77
Q

Cognitive, interpersonal or technical nursing intervention:

provide appropriate sensory stimulation

78
Q

Cognitive, interpersonal or technical nursing intervention:

mobilize or maintain equipment

79
Q

What is the general format for care plans or concept maps?

A
  • nursing diagnostic statement
  • patient goals
  • nursing interventions
80
Q

What happens during implementation phase?

A

(5th part of nursing care plan)
-focus on what nurse will do:
initiation of plan, evaluation of response, reassessment

81
Q

Transfer of responsibility for performance of a task to another individual while retaining accountability for the outcome

A

delegation

82
Q

If a task is delegated and it does not get completed, who is at fault- nurse or person they delegated to?

83
Q

5 priniciples of delegation

A
  1. right person
  2. right task
  3. right circumstance
  4. right communication
  5. right evaluation
84
Q

Righ tperson- delegation

A

trained to perform the task, willing, and legally able

85
Q

Right task- delegation

A
  • set procedure
  • familiar to person delegated to do it
  • involve minimal risk
86
Q

Right circumstance - delegation

A

-patient must be stable
-able to supervise person performing
(don’t have to supervise but must have the ability to do so)

87
Q

Right communication- delegation

A

communicate what needs to be done and what is expected

88
Q

Right evaluation- delegation

A

check if the task was performed and documented

-provide feedback in needed

89
Q

What cannot be delegated to UAP/CNA/LPN(4)

A
  • education
  • assessment
  • clinical judgement
  • evaluation
90
Q

What happens during evaluation?

A

(last phase of nursing process)

-was the plan of care successful in addressing the problem

FOUNDATIONS 310 (28 decks)

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