Nursing Process Flashcards
standardized nursing language:
defines nursing’s _____ and _____ in healthcare
contribution and impact
*defines what nurses do
standardized nursing language:
gives nurses more ______ and ______
EB outcomes and interventions
standardized nursing language:
is easily integrated into ____
EMR
standardized nursing language:
standardizes ______ for nursing curriculum
knowledge
standardized nursing language:
promotes _______
nursing research
standardized nursing language example?
nurses : altered skin integrity
others : wound
nursing process:
human response to ____ or ____ problem
actual or potential
aspects of the nursing process?
holistic
scientific
EBP
individualized
analyzed information
what is included in the clinical judgement measurement model?
recognize and analyze cues
prioritize hypotheses
generate solutions
take actions
evaluate outcomes
*parallels ADPIE
what is ADPIE?
assessment
diagnosis
planning
implementing
evaluating
analyze _____ vs _____ to create a nursing diagnosis
actual vs risk
how many parts in an actual nursing diagnosis?
3
how many parts in a risk nursing diagnosis?
2
what two goals are involved in planning?
patient outcomes
nursing interventions
what does a nursing care plan allow for?
individualized care
set priorities
facilitate communication
promote continuity
evaluate patient response
create a record
characteristics of nursing assessments?
purposeful
prioritized
complete
systematic
accurate
relevant
recorded in standard manner
what are the different types of assessment?
initial- admission and shift
focused
time-lapsed
admission assessment requirements?
completed within 8 hours and in depth (3/4 pages)
*sets baseline for the hospital stay
shift assessment requirements?
quicker and shorter (1/2 pages)
*sets baseline for shift duration
what is a focused assessment?
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
what is time-lapsed assessment?
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
what is critical thinking?
mental process of recognizing, analyzing, applying, and evaluating information to reach a conclusion
what is clinical thinking?
using critical thinking in a clinical setting to make nursing care decisions based on EBP
which is the best source of assessment data?
patient
followed by
family and significant others
patient record
other healthcare professionals
what is a nursing diagnosis?
a clinical judgement about an individual’s responses to actual or potential health problems
nursing diagnosis provides the basis for selection of ________ and the ________ to achieve the set outcomes
patient outcomes and nursing interventions
steps in diagnostic process:
create a list of ________
suspected process
steps in diagnostic process:
name _____ and _____ problems/diagnoses and clarify what is _____ or _____ contributing to them
actual and potential
causing or contributing
steps in diagnostic process:
determine ______ that must be managed for a risk DX
risk factors
steps in diagnostic process:
confirm _____ for an actual DX
defining characteristics
steps in diagnostic process:
prioritize _____
nursing diagnoses
what are the three parts of an actual nursing diagnosis?
problem, etiology (cause of problem), defining characteristics (evidence)
how do you phrase an actual nursing diagnosis?
problem R/T etiology AEB defining characteristics (subjective and objective data that supports problem)
what is a secondary etiology?
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)
what does etiology drive?
nursing interventions
*what we will do
what are the nursing diagnoses that have etiologies?
problem (actual) and syndromes
what component are risk diagnoses missing?
defining characteristics - they don’t have the problem but are at risk for it
which nursing diagnoses have risk factors?
risk diagnoses
what is the nursing dx for pneumonia?
ineffective airway clearance
what is the nursing dx for amputation?
disturbed body image
what is the nursing dx for type 2 diabetes mellitus?
risk for unstable blood glucose
what is the nursing dx for post-op prostatectomy?
impaired urinary elimination
what nursing dx for cerebrovascular accident?
self care deficit: dressing
maslow’s hierarchy of needs:
level 1
physiological needs
*most important
maslow’s hierarchy of needs:
level 2
safety and security
maslow’s hierarchy of needs:
level 3
love and belonging
maslow’s hierarchy of needs:
level 4
self esteem
maslow’s hierarchy of needs:
level 5
self actualization
what is maslow’s used for?
to set priorities
benefits of nursing diagnoses:
______ patient care
individualizing
benefits of nursing diagnoses:
defining ______ to healthcare admins, legislators, and providers
domain of nursing
benefits of nursing diagnoses:
seeking funding for nursing and ______
reimbursement for nursing services
problem states drives _____
patient outcomes
what are the 4 types of outcomes?
cognitive
psychomotor
affective
physiologic
what is a cognitive outcome?
increase in patient knowledge
what is a psychomotor outcome?
patients achievement of new skills
what is an affective outcome?
changes in patient values, beliefs, and attitudes
what is a physiologic outcome?
physical changes in the patient
which outcome is the hardest to change/achieve?
affective
smart goals?
specific
measurable
attainable
realistic
time bound
what are the actions based on patient response to POC in the evaluation phase?
direct future care
terminate
modify
continue
what are the never events?
pressure injuries 3 and 4
falls and trauma
surgical site infection
vascular-catheter assoc infection
CAUTI
admin of incompatible blood
what are the always events?
identifying patients by more than one source
mandatory read backs
med error reduction strategies
result tracking
available critical information
terminate POC?
when each expected outcome is achieved
modify POC?
if there are difficulties achieving outcomes
continue POC?
if more time is needed to achieve outcomes