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Fundamentals NUR 220 > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

standardized nursing language:
defines nursing’s _____ and _____ in healthcare

A

contribution and impact
*defines what nurses do

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2
Q

standardized nursing language:
gives nurses more ______ and ______

A

EB outcomes and interventions

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3
Q

standardized nursing language:
is easily integrated into ____

A

EMR

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4
Q

standardized nursing language:
standardizes ______ for nursing curriculum

A

knowledge

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5
Q

standardized nursing language:
promotes _______

A

nursing research

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6
Q

standardized nursing language example?

A

nurses : altered skin integrity
others : wound

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7
Q

nursing process:
human response to ____ or ____ problem

A

actual or potential

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8
Q

aspects of the nursing process?

A

holistic
scientific
EBP
individualized
analyzed information

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9
Q

what is included in the clinical judgement measurement model?

A

recognize and analyze cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes
*parallels ADPIE

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10
Q

what is ADPIE?

A

assessment
diagnosis
planning
implementing
evaluating

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11
Q

analyze _____ vs _____ to create a nursing diagnosis

A

actual vs risk

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12
Q

how many parts in an actual nursing diagnosis?

A

3

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13
Q

how many parts in a risk nursing diagnosis?

A

2

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14
Q

what two goals are involved in planning?

A

patient outcomes
nursing interventions

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15
Q

what does a nursing care plan allow for?

A

individualized care
set priorities
facilitate communication
promote continuity
evaluate patient response
create a record

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16
Q

characteristics of nursing assessments?

A

purposeful
prioritized
complete
systematic
accurate
relevant
recorded in standard manner

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17
Q

what are the different types of assessment?

A

initial- admission and shift
focused
time-lapsed

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18
Q

admission assessment requirements?

A

completed within 8 hours and in depth (3/4 pages)
*sets baseline for the hospital stay

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19
Q

shift assessment requirements?

A

quicker and shorter (1/2 pages)
*sets baseline for shift duration

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20
Q

what is a focused assessment?

A

focuses on only ONE system
*assess problems that could be connected to primary issue
ex. not listening to bowel sounds if problem is with the heart

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21
Q

what is time-lapsed assessment?

A

looking at one thing over a specified period of time (like a follow up but with a specific purpose)
ex. skin wound assessed, comes back in two weeks (predetermined time) to assess same wound

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22
Q

what is critical thinking?

A

mental process of recognizing, analyzing, applying, and evaluating information to reach a conclusion

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23
Q

what is clinical thinking?

A

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

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24
Q

which is the best source of assessment data?

A

patient
followed by
family and significant others
patient record
other healthcare professionals

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25
Q

what is a nursing diagnosis?

A

a clinical judgement about an individual’s responses to actual or potential health problems

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26
Q

nursing diagnosis provides the basis for selection of ________ and the ________ to achieve the set outcomes

A

patient outcomes and nursing interventions

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27
Q

steps in diagnostic process:
create a list of ________

A

suspected process

28
Q

steps in diagnostic process:
name _____ and _____ problems/diagnoses and clarify what is _____ or _____ contributing to them

A

actual and potential
causing or contributing

29
Q

steps in diagnostic process:
determine ______ that must be managed for a risk DX

A

risk factors

30
Q

steps in diagnostic process:
confirm _____ for an actual DX

A

defining characteristics

31
Q

steps in diagnostic process:
prioritize _____

A

nursing diagnoses

32
Q

what are the three parts of an actual nursing diagnosis?

A

problem, etiology (cause of problem), defining characteristics (evidence)

33
Q

how do you phrase an actual nursing diagnosis?

A

problem R/T etiology AEB defining characteristics (subjective and objective data that supports problem)

34
Q

what is a secondary etiology?

A

usually a medical diagnosis
*used for clarity
ex. nurses cannot diagnose arthritis so you would say
pain (problem) R/T tissue inflammation (etiology) secondary to arthritis (secondary etiology)

35
Q

what does etiology drive?

A

nursing interventions
*what we will do

36
Q

what are the nursing diagnoses that have etiologies?

A

problem (actual) and syndromes

37
Q

what component are risk diagnoses missing?

A

defining characteristics - they don’t have the problem but are at risk for it

38
Q

which nursing diagnoses have risk factors?

A

risk diagnoses

39
Q

what is the nursing dx for pneumonia?

A

ineffective airway clearance

40
Q

what is the nursing dx for amputation?

A

disturbed body image

41
Q

what is the nursing dx for type 2 diabetes mellitus?

A

risk for unstable blood glucose

42
Q

what is the nursing dx for post-op prostatectomy?

A

impaired urinary elimination

43
Q

what nursing dx for cerebrovascular accident?

A

self care deficit: dressing

44
Q

maslow’s hierarchy of needs:
level 1

A

physiological needs
*most important

45
Q

maslow’s hierarchy of needs:
level 2

A

safety and security

46
Q

maslow’s hierarchy of needs:
level 3

A

love and belonging

47
Q

maslow’s hierarchy of needs:
level 4

A

self esteem

48
Q

maslow’s hierarchy of needs:
level 5

A

self actualization

49
Q

what is maslow’s used for?

A

to set priorities

50
Q

benefits of nursing diagnoses:
______ patient care

A

individualizing

51
Q

benefits of nursing diagnoses:
defining ______ to healthcare admins, legislators, and providers

A

domain of nursing

52
Q

benefits of nursing diagnoses:
seeking funding for nursing and ______

A

reimbursement for nursing services

53
Q

problem states drives _____

A

patient outcomes

54
Q

what are the 4 types of outcomes?

A

cognitive
psychomotor
affective
physiologic

55
Q

what is a cognitive outcome?

A

increase in patient knowledge

56
Q

what is a psychomotor outcome?

A

patients achievement of new skills

57
Q

what is an affective outcome?

A

changes in patient values, beliefs, and attitudes

58
Q

what is a physiologic outcome?

A

physical changes in the patient

59
Q

which outcome is the hardest to change/achieve?

A

affective

60
Q

smart goals?

A

specific
measurable
attainable
realistic
time bound

61
Q

what are the actions based on patient response to POC in the evaluation phase?

A

direct future care
terminate
modify
continue

62
Q

what are the never events?

A

pressure injuries 3 and 4
falls and trauma
surgical site infection
vascular-catheter assoc infection
CAUTI
admin of incompatible blood

63
Q

what are the always events?

A

identifying patients by more than one source
mandatory read backs
med error reduction strategies
result tracking
available critical information

64
Q

terminate POC?

A

when each expected outcome is achieved

65
Q

modify POC?

A

if there are difficulties achieving outcomes

66
Q

continue POC?

A

if more time is needed to achieve outcomes

Fundamentals NUR 220 (21 decks)

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