Nursing Process Flashcards

1
Q

Is a systematic, rational method of planning and providing individualized nursing care.

A

Nursing process

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2
Q

Who originated the term nursing process? When?

A

Hall (1955), Johnson (1959), Orlando (1961), Widenbach (1963)

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3
Q

The use of the nursing process in clinical practice gained additional legitimacy in?(year) when the phases were included in American Nurses Association (ANA)

A

1973

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4
Q

Characteristics of the nursing process:

A

Cyclic and dynamic
Client-centered
Focused on problem solving and decision making
Interpersonal and collaborative style
Universal applicability

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5
Q

Data in each phase provides data in the next phase.

A

Cyclic and dynamic

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6
Q

Regularly repeated event or sequence of events that are continuously changing.

A

Cyclic and dynamic

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7
Q

The nurse organizes the plan of care according to the client problems and needs rather than nursing goals.

A

Client-centered

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8
Q

It is involved in every phase of the nursing process.

A

Decision-making

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9
Q

This facilitates the individualization of the nurse’s plan of care.

A

Decision-making

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10
Q

It requires the nurse to communicate directly and consistently with clients and families to meet their needs.

A

Interpersonal and collaborative

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11
Q

Obtaining an information and that clarifies the nature of the problem and suggests possible solutions.

A

Problem solving

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12
Q

A critical thinking process for choosing the best actions to meet a desired goal.

A

Decision-making

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13
Q

It is an adaptation of problem solving and decision making.

A

Nursing process

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14
Q

Nursing process is used as a framework for nursing care in all types of healthcare settings, with clients of all age groups.

A

Universal applicability

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15
Q

Intellectually disciplines process of actively and skillfully conceptualizing, applying, analyzing, and/or evaluating information gathered from, or generated observation, experience, reflection, reasoning or communication, as a guide to belief and action.

A

Critical thinking

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16
Q

Collection, organization, validation, documentation of data

A

Assessment

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17
Q

Purpose of assessment

A

To establish database about the client’s response to health concerns or illness and the ability to manage healthcare needs

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18
Q

Analysis of data
Identification of health problems, risks, and strengths
Formulation of diagnostic statements

A

Diagnosing

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19
Q

Prioritization of problems/diagnoses
Formulation of goals/desired outcomes

A

Planning

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20
Q

Selection of nursing interventions
Writing of nursing orders

A

Planning

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21
Q

Purpose of planning

A

To develop a health care plan reflective of specific objective.

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22
Q

Reassessment of the client
Determination of the nurse’s need for assistance

A

Implementation

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23
Q

Implementation of nursing interventions
Supervision of delegated care

A

Implementation

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24
Q

Documentation of nursing activities

A

Implementation

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25
Q

Collection of data related to outcomes
Comparison of data with outcomes.

A

Evaluation

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26
Q

A systematic and continuous collection, organization, validation, and documentation of data (information).

A

Assessment

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27
Q

The process of gathering information about client’s health status.

A

Data collection

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28
Q

Covert data

A

Symptoms

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29
Q

Overt data

A

Signs

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30
Q

Apparent only to the person affected and can be verified only by the person.

A

Subjective data

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31
Q

Detectable by an observer or can be measured or tested against accepted standard.

A

Objective data

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32
Q

Conscious, deliberate skill involving the use of senses.

A

Observation

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33
Q

Planned communication or a conversation with a purpose.

A

Interview

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34
Q

Highly structured and elicits specific information.

A

Directive interview

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35
Q

Nurse allows client to control purpose, subject matter and pacing.

A

Non-directive interview

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36
Q

Major method used in the physical health assessment.

A

Examining

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37
Q

A systematic data collection method that uses observation to detect health problems through the use of the techniques: inspection, auscultation, palpation, and percussion.

A

Physical assessment

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38
Q

Information that does not change over time such as race or blood type.

A

Constant data

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39
Q

Data that can change quickly, frequently, or rarely and include such data as blood pressure, level of pain, and age.

A

Variable data

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40
Q

The nurse uses the written format or computerized format that organizes the assessment data systematically.

A

Nursing health history
Nursing assessment or nursing databases form

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41
Q

Is the process of making clinical judgment about a client’s actual or potential health problems.

A

Diagnosing

42
Q

Diagnosing refers to the reasoning process, whereas the term __________ is a statement or conclusion regarding the nature of a phenomenon.

A

Diagnosis

43
Q

Contains a diagnostic phrase or diagnostic label followed by an etiology phase.

A

Nursing diagnosis

44
Q

Is a statement of the client’s problem

A

Diagnostic phrase or label

45
Q

The causal relationship between the client’s problem or risk factors.

A

Etiology

46
Q

It is the act of “double-checking” or verifying data to confirm that the data is accurate and factual.

A

Validation of data

47
Q

The process of determining the relatedness of facts and determining whether any patterns are present, whether the data represent isolated incidents and whether the data are significant.

A

Clustering cues

48
Q

Can be an aid to mobilizing health and regenerative processes.

A

Strength

49
Q

Formulation of diagnostic statements?

A

PES Format
(Problem, Etiology, Signs and Symptoms)

50
Q

Statement’s of client’s health need/concern/problem (based from NANDA)

A

Problem

51
Q

Factors contributing to or probable causes of responses.

A

Etiology

52
Q

Defining characteristics manifested by the client.

A

Signs and symptoms

53
Q

Provides the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable.

A

NANDA

54
Q

Types of Nursing Diagnoses:
Present at the time of assessment; based on associated manifestations.

A

Actual

55
Q

Types of Nursing Diagnoses:
A clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

A

Potential/High-risk

56
Q

Types of Nursing Diagnoses:
Describes human responses to levels of wellness in an individual, family or community that have a readiness for enhancement

A

Wellness

57
Q

Types of Nursing Diagnoses:
Evidence about a health problem is incomplete or unclear; requires more data either to support or refuse it.

A

Possible Nursing Diagnosis

58
Q

Types of Nursing Diagnoses:
Associated with a cluster of other diagnosis.

A

Syndrome diagnosis

59
Q

The process of designing nursing activities required to prevent, reduce or eliminate client’s health problems.

A

Planning

60
Q

Is the process of establishing a preferential sequence for addressing nursing diagnosis and interventions.

A

Priority setting

61
Q

Considerations in setting priorities:

A

Triage concept
Maslow’s Hierarchy of Needs
Availability of resources
Patient’s preferences

62
Q

Statement reflective of desired changes in the behavior of the client which a health intervention seeks to bring about.

A

Goal

63
Q

A positive behavior/what a nurse wants to happen to the patient after a series of intervention.

A

Terminal behavior

64
Q

Types of Terminal Behavior:
Concerns with knowledge, understanding, remembering, intellectual, capacity, decision-making.

A

Cognitive

65
Q

Types of Terminal Behavior:
Refers to feelings, emotions, attitude

A

Affective

66
Q

Types of Terminal Behavior:
Refers to physical capabilities, performances, technical skills

A

Psychomotor

67
Q

Types of Terminal Behavior:
Refers to changes in bodily responses

A

Physiologic

68
Q

Describe specific and measurable client responses and help the nurse evaluate the effectiveness of the nursing intervention.

A

Client’s goals/desired outcomes

69
Q

Types of desired outcomes:
Require care for a short time - acute care setting

A

Short term

70
Q

Types of desired outcomes:
Chronic health problems and those who live in nursing homes, rehab centers, extended care facilities.

A

Long term

71
Q

Components of goals/desired outcomes:

A

Subject
Condition
Terminal behavior
Parameter

72
Q

Components of goals:
Patient and problem

A

Subject

73
Q

Components of goals:
Time under which the change in behavior is achieved

A

Condition

74
Q

Components of goals:
An observable activity the patient demonstrates

A

Terminal behavior

75
Q

Components of goals:
Reflect acceptable performance

A

Parameter

76
Q

Characteristics of a good goal/objective:

A

(SMART)
Specific
Measurable
Attainable
Realistic
Time framed

77
Q

The blueprint of the nursing process/nursing practice

A

Nursing care plan

78
Q

Brief discussion on how the etiology resulted to a problem

A

Inference

79
Q

The “doing” phase

A

Implementation

80
Q

The execution of the nursing care plan

A

Implementation

81
Q

Measures provided by the nurse through which changes in patient’s behavior are brought about.

A

Nursing intervention

82
Q

Principles involved in selecting nursing interventions and activities

A

Prioritization
Rationalization
Use of available resources

83
Q

Categories of Interventions according to Legal implication

A

Independent
Collaborative

84
Q

Categories of interventions according to approach

A

Facilitative
Developmental
Supportive

85
Q

Interventions which concern on removal of barriers to health care

A

Facilitative

86
Q

Actions that improve patient’s ability to cope with health-illness situation

A

Developmental

87
Q

Interventions done to patient who cannot do usual work

A

Supportive

88
Q

Interventions that are implemented to patient’s by virtue of the nurse’s education, practice and training

A

Supplemental

89
Q

Considerations when selecting nursing interventions:

A

Economy of time, effort and materials
Safety
Respect and privacy
Appropriateness

90
Q

Degree of assistance for patients:

A

Wholly compensatory
Partly compensatory
Educative-supportive

91
Q

Value determine of the efficiency of care based on previously established goal

A

Evaluation

92
Q

Purposes of evaluation:

A

Documenting responses to interventions
Evaluating effectiveness of interventions
Evaluating outcome achievement
Reviewing health care plan

93
Q

Types of evaluation: Done every after specific care given to check its efficiency and effectiveness

A

On-going

94
Q

Types of evaluation:
Scheduled evaluation, done every after series of interventions

A

Intermittent

95
Q

Types of evaluation:
Done at the end of the processes after all interventions had been implemented

A

Terminal

96
Q

Steps in evaluation:

A

Evaluate expected outcome/goal achievement
Terminate for goals achieved
Re-assess and revise care plan as needed

97
Q

Approaches to qualify evaluation:

A

Structure
Process
Outcome impact

98
Q

Dimensions of evaluation:

A

Efficiency
Effectiveness
Adequacy of interventions
Appropriateness

99
Q

Four types of assessments

A

Initial nursing assessment
Problem-focused assessment
Emergency assessment
Time-lapsed assessment

100
Q

Nursing assessments focus on a client’s ____________ to a health problem.

A

responses