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Fundamentals of Nursing > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

nursing process
human response to __________ or ___________ problem

A

actual, potential

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2
Q

nursing process

A

holistic
scientific
EBP
individualized
analyze information

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3
Q

critical thinking
mental process of

A

recognizing, analyzing, applying and evaluating information to reach a conclusion

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4
Q

clinical thinking

A

use critical thinking in a clinical setting to make nursing care decisions based on EBP

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5
Q

standardized language

A

always using the same wording

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6
Q

do nurses treat the medical diagnosis

A

no

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7
Q

benefits of standardized nursing language

A

defines nursing contribution and impact in healthcare
defines what nurses do
gives nurses more EB outcomes and interventions
easily integrated into EMR
standardizes knowledge for nursing curriculum
promotes nursing research

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8
Q

ADPIE

A

assessment
diagnosis
planning
implementation
evaulation

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9
Q

what step comes first

A

assessment

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10
Q

what comes after assessment

A

diagnosis

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11
Q

what are the 2 parts of diagnosis

A

actual- 3 part
risk - 2 part

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12
Q

what comes after diagnosis

A

planning

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13
Q

what are the two parts of planning

A

patient outcomes
nursing interventions

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14
Q

what comes after planning

A

implement

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15
Q

what comes after implementation

A

evaulation

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16
Q

what does evaluation lead back to

A

patient outcomes

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17
Q

what are the types of assessment

A

inital
- admission
- shift
focused
time lapsed

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18
Q

what is an admission assessment

A

completed within 8 hours of admission (mandated by joint commission)
baseline for hospitalization

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19
Q

what is a shift assessment

A

what you do at the beginning of shift
baseline for day

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20
Q

what is a focused assessment

A

only focus on one system

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21
Q

a patient returns a few days after an appointment for asthma unplanned
what assessment

A

focused

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22
Q

what is a time lapsed assessment

A

treatment for specific time
purposely come back after certain time

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23
Q

a patient returns for a follow up appointment 2 months after a previous appointment for COPD
what assessment

A

time lapsed

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24
Q

what is the best source for data

A

patient

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25
if the patient is not available what is the next best source for data
family and significant others
26
if the patient and family/significant others are not available what is the next best source for data
patient record
27
if the patient, family/significant others, records, are not available what is the next best source for data
other healthcare professionals
28
subjective
what the patient says
29
objective
measurable and observable
30
nursing diagnosis
clinical judgment about an individuals responses to actual or potential health problems
31
nursing diagnosis provides the basis for selection of __________ _______ and __________ ______________ to achieve the set outcomes
patient outcomes, nursing interventions
32
steps in diagnosis process
- create a list of suspected problems - name actual and problems/diagnoses and clarify what is causing or contrubituing to them - determine risk factors that must be managed for a risk DX - confirm defining characteristics for an actual DX - prioritize nursing diagnoses
33
2 nursing diagnosis in fundamentals class
problem focused diagnosis risk diagnosis
34
problem focused diagnosis
actual problem
35
risk diagnosis
risk of problem developing
36
what is an etiology
cause of the problem
37
what are the only 2 nursing diagnosis that have etiologies
problem (actual) and syndromes
38
when would there be a medical diagnosis in a nursing diagnosis
secondary
39
what comes first in a actual nursing diagnosis
problem
40
what comes after problem
r/t etiology
41
what comes after etiology
defining characterisitcs
42
problem drives
outcomes
43
etiology drives
nursing intervetnions
44
what is included in a actual diagnosis
problem R/T etiology AEB defining characterisitcs
45
what is included in a at risk diganosis
problem statment AED risk factor
46
are there defining characteristics in a at risk diagnosis
no because it doesn't exist yet
47
what are the diagnosis that have risk factors
risk diagnosis
48
nursing diagnosis is in response to the
medical diagnosis
49
what might be a nursing diagnosis for pneumonia
ineffective airway clearance
50
what might be a nursing diagnosis for amputation
disturbed body image
51
what might be a nursing diagnosis for type 2 diabetes
risk for unstable blood glucose
52
5 levels to Maslow
physiologic safety and security love and belonging self esteem self actualization
53
what belongs in physiologic needs
oxygen food elmination temp control sex movement rest comfort
54
what belongs in safety and security
safety from threat, protection, continuity, stability, lack of danger
55
what belongs in love and belonging
affiliation, affection, intamacy, support, reasurance
56
what belongs in self esteem
sense of worth, self respect, independence, dignity, privacy, self reliance
57
what belongs in self actulization
recognition and realization of ones potential, growth, health, and autonomy
58
affection belongs in what category
love and belonging
59
sense of self worth belongs in what category
self esteem
60
lack of danger belongs in what category
safety and security
61
growth belongs in what category
self actualization
62
comfort belongs in what category
physiologic
63
support belongs in what category
love and beloning
64
privacy belongs in what category
self esteem
65
autonomy belongs in what category
self actualization
66
food belongs in what category
physiologic
67
benefits of nursing diagnosis
individualizing care defining domain of nursing reimbursement for nursing services
68
problem drives
patient outcomes
69
etiology drives
nursing interventions
70
nursing care plan allows
individualize care set priorities facilitate communication promote continuity evaluate patent response create a record
71
4 types of outcomes
cognitive psychomotor affective physiologic
72
cognitive outcome
increase patient knowlegde teaching
73
psychomotor outcome
patients achèvement of new skills demonstrate what was teached
74
affective outcome
changes in patients values, beliefs, and attitudes change habits
75
physiologic outcomes
physical change in patient
76
what can we do with a care plan after evaulation
terminate, continue, modify
77
terminate
when each expected outcome is achieved
78
modify
when there are difficulties
79
continue
more time is needed to achieve the outcomes
80
NEVER EVENTS
pressure injury stages 3-4 falls trauma surgical site infection vascular catheter associated infection CAUTI administration of incompatible blood air embolism foreigin object in body after surgery
81
foley care
good peri care clean 6 in down cath secure to leg green clip on bedding no dependent loop bag off floor
82
ALWAYS EVENTS
including patient identifications by more than one source mandatory read backs disclosure of adverse outcomes medication error reduction strategies tracking of critical imaging, lab and pathology results critical information avaibale at handoffs or transitions in care

Fundamentals of Nursing (23 decks)

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