Nursing Process Flashcards
nursing process
human response to __________ or ___________ problem
actual, potential
nursing process
holistic
scientific
EBP
individualized
analyze information
critical thinking
mental process of
recognizing, analyzing, applying and evaluating information to reach a conclusion
clinical thinking
use critical thinking in a clinical setting to make nursing care decisions based on EBP
standardized language
always using the same wording
do nurses treat the medical diagnosis
no
benefits of standardized nursing language
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
ADPIE
assessment
diagnosis
planning
implementation
evaulation
what step comes first
assessment
what comes after assessment
diagnosis
what are the 2 parts of diagnosis
actual- 3 part
risk - 2 part
what comes after diagnosis
planning
what are the two parts of planning
patient outcomes
nursing interventions
what comes after planning
implement
what comes after implementation
evaulation
what does evaluation lead back to
patient outcomes
what are the types of assessment
inital
- admission
- shift
focused
time lapsed
what is an admission assessment
completed within 8 hours of admission (mandated by joint commission)
baseline for hospitalization
what is a shift assessment
what you do at the beginning of shift
baseline for day
what is a focused assessment
only focus on one system
a patient returns a few days after an appointment for asthma unplanned
what assessment
focused
what is a time lapsed assessment
treatment for specific time
purposely come back after certain time
a patient returns for a follow up appointment 2 months after a previous appointment for COPD
what assessment
time lapsed
what is the best source for data
patient
if the patient is not available what is the next best source for data
family and significant others
if the patient and family/significant others are not available what is the next best source for data
patient record
if the patient, family/significant others, records, are not available what is the next best source for data
other healthcare professionals
subjective
what the patient says
objective
measurable and observable
nursing diagnosis
clinical judgment about an individuals responses to actual or potential health problems
nursing diagnosis provides the basis for selection of __________ _______ and __________ ______________ to achieve the set outcomes
patient outcomes, nursing interventions
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
2 nursing diagnosis in fundamentals class
problem focused diagnosis
risk diagnosis
problem focused diagnosis
actual problem
risk diagnosis
risk of problem developing
what is an etiology
cause of the problem
what are the only 2 nursing diagnosis that have etiologies
problem (actual) and syndromes
when would there be a medical diagnosis in a nursing diagnosis
secondary
what comes first in a actual nursing diagnosis
problem
what comes after problem
r/t etiology
what comes after etiology
defining characterisitcs
problem drives
outcomes
etiology drives
nursing intervetnions
what is included in a actual diagnosis
problem
R/T
etiology
AEB
defining characterisitcs
what is included in a at risk diganosis
problem statment
AED
risk factor
are there defining characteristics in a at risk diagnosis
no because it doesn’t exist yet
what are the diagnosis that have risk factors
risk diagnosis
nursing diagnosis is in response to the
medical diagnosis
what might be a nursing diagnosis for
pneumonia
ineffective airway clearance
what might be a nursing diagnosis for
amputation
disturbed body image
what might be a nursing diagnosis for
type 2 diabetes
risk for unstable blood glucose
5 levels to Maslow
physiologic
safety and security
love and belonging
self esteem
self actualization
what belongs in physiologic needs
oxygen
food
elmination
temp control
sex
movement
rest
comfort
what belongs in safety and security
safety from threat, protection, continuity, stability, lack of danger
what belongs in love and belonging
affiliation, affection, intamacy, support, reasurance
what belongs in self esteem
sense of worth, self respect, independence, dignity, privacy, self reliance
what belongs in self actulization
recognition and realization of ones potential, growth, health, and autonomy
affection belongs in what category
love and belonging
sense of self worth belongs in what category
self esteem
lack of danger belongs in what category
safety and security
growth belongs in what category
self actualization
comfort belongs in what category
physiologic
support belongs in what category
love and beloning
privacy belongs in what category
self esteem
autonomy belongs in what category
self actualization
food belongs in what category
physiologic
benefits of nursing diagnosis
individualizing care
defining domain of nursing
reimbursement for nursing services
problem drives
patient outcomes
etiology drives
nursing interventions
nursing care plan allows
individualize care
set priorities
facilitate communication
promote continuity
evaluate patent response
create a record
4 types of outcomes
cognitive
psychomotor
affective
physiologic
cognitive outcome
increase patient knowlegde
teaching
psychomotor outcome
patients achèvement of new skills
demonstrate what was teached
affective outcome
changes in patients values, beliefs, and attitudes
change habits
physiologic outcomes
physical change in patient
what can we do with a care plan after evaulation
terminate, continue, modify
terminate
when each expected outcome is achieved
modify
when there are difficulties
continue
more time is needed to achieve the outcomes
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
foley care
good peri care
clean 6 in down cath
secure to leg
green clip on bedding
no dependent loop
bag off floor
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
