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Health Assessment - RLE > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q
  • is a systematic problem-solving process that guide all nursing actions
A

NURSING PROCESS

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2
Q
  • This is the type of thinking and doing that nurses use in their practice
A

NURSING PROCESS

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3
Q
  • Is a critical thinking that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
A

NURSING PROCESS

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4
Q
  • The cornerstone of the nursing profession
A

NURSING PROCESS

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5
Q
  • The skill is essential for the clinical application of knowledge and theory in nursing practice
A

NURSING PROCESS

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6
Q

NURSING PROCESS is synonymous with

A

problem solving approach

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7
Q

[What and In?] Dorothy Johnson
Introduced three steps of nursing process:

A

1959
- Assessment
- Decision
- Nursing Action

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8
Q

Lydia Hall
- originated the term “nursing process” in

A

1955

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9
Q

Lydia Hall
- originated the term “nursing process” in 1955
3 steps:

A
  • Note observation
  • Ministration of care
  • Validation
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10
Q

[What and In?] Ida Jean Orlando
- identified three steps of nursing process in

A

1961
- Client’s Behavior
- Nurse’s Reaction
- Nurse’s Action

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11
Q

Yura and Walsh has the 4 components of nursing process:

A

1961
- Assessing
- Planning
- Implementing
- Evaluating

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12
Q

Knowles
- described nursing process:

A

1961
- Discover - Do
- Delve - Discriminate
- Decide

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13
Q

What is the Nursing Process?

A

Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation

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14
Q

the nurse collects patient’s health data

A

Assessment

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15
Q

a systematic, dynamic process by which the nurse, through interactions with the client, significant others and health care providers, collects and analyzes data about the client

A

Assessment

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16
Q

gathering information about the client’s status

A

Data collection

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17
Q

Types of Data

A

Subjective Data
Objective Data

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18
Q
  • Coming from the mouth of patient or significant others
A

Subjective Data

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19
Q
  • Symptoms or covert data
A

Subjective Data

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20
Q
  • Information told to the nurse by the client, family or community
A

Subjective Data

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21
Q
  • Apparent only to the person affected and can be described or verified only by that person
A

Subjective Data

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22
Q
  • Client’s sensations, feelings, values, beliefs, attitudes, perception of personal health status and life situation
A

Subjective Data

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23
Q
  • What health care providers observe
A

Objective Data

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24
Q
  • Signs or overt data
A

Objective Data

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25
Q
  • Information gathered through a physical assessment or from laboratory or diagnostic test
A

Objective Data

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26
Q
  • It can be measured or observed by the nurse or other health care providers
A

Objective Data

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27
Q

Sources of Data

A

Primary Data
Secondary Data

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28
Q
  • Subjective or objective data obtained from the client; what the client says or what you observe
A

Primary Data

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29
Q
  • All sources other than the client (significant others, client records, health care professionals)
A

Secondary Data

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30
Q

Methods of Data Collection

A

Observation
Interview

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31
Q
  • Deliberate use of all five senses to gather and interpret patient and environment
A

Observation

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32
Q
  • “All that you can see, hear, feel, smell or sense becomes data in the context of assessment”
A

Observation

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33
Q
  • Planned communication or conversation with a purpose
A

Interview

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34
Q
  • Purposeful structural communication in which you question the patient to gather subjective data for the nursing database
A

Nursing Interview

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35
Q
  • The nurse analyzes the data gathered during assessment and identifies problem areas for the patient. The nurse then makes a diagnosis.
A

Diagnosis

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36
Q
  • Applies to the label when nurses assign meaning to collected data appropriately with NANDA-I-approved nursing diagnosis
A

Nursing Diagnosis

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37
Q
  • Made by the physician or advance healthcare practitioner that deals more with the disease, medical condition or pathological state only a practitioner can treat
A

Medical Diagnosis

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38
Q

Components of Nursing Diagnosis

A
  • Problem Statement/ Diagnostic Label
  • Etiology
  • Risk Factors
  • Defining Characteristics
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39
Q
  • Describe the client’s health problem or response for which nursing therapy is given as concisely as possible
A

Problem Statement/Diagnostic Label

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40
Q
  • Words that have been added to some NANDA
A

Qualifiers

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41
Q

inadequate, incomplete

A

Deficient

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42
Q

made worse, damaged

A

impaired

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43
Q

lesser in size

A

decreased

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44
Q

not producing the desired effect

A

ineffective

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45
Q

to make vulnerable to threat

A

comprised

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46
Q
  • Also known as “related factors”
A

Etiology

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47
Q
  • Component of a nursing diagnosis label that identifies one or more probable cases of the health problem
A

Etiology

48
Q
  • The conditions involved in the development of the problem
A

Etiology

49
Q
  • Gives direction to the required nursing therapy
A

Etiology

50
Q

Etiology is linked to the problem statement with the phrase

A

“related to”

51
Q
  • Used instead of Etiological factors for risk nursing diagnosis
A

Risk Factors

52
Q

are forces that puts an individual or group at an increased vulnerability to an unhealthy condition

A

Risk Factors

53
Q
  • “As manifested by guarding behavior”
A

Signs and Symptoms

54
Q
  • “as evidenced by”
  • “as manifested by”
A

Defining Characteristics

55
Q
  • The clusters of signs and symptoms that indicate the presence of a particular diagnostic label
A

Defining Characteristics

56
Q

Types of Nursing Diagnosis

A
  • Actual Nursing Diagnosis
  • Risk Nursing Diagnosis
  • Possible Nursing Diagnosis
  • Wellness Diagnosis
  • Syndrome Diagnosis
57
Q
  • Is a client problem that is present at the time of the nursing assessment. Their diagnoses are based on the presence of associated signs and symptoms
A

Actual Nursing Diagnosis

58
Q
  • Refers to the problem that exist at the present moment
A

Actual Nursing Diagnosis

59
Q

Formula of Actual Nursing Diagnosis

A

Patient’s Problem + Etiology + Signs and Symptoms = Actual Nursing Diagnosis

60
Q
  • Are 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

Risk Nursing Diagnosis

61
Q
  • A clinical judgment that is more vulnerable to develop the problem
A

Risk Nursing Diagnosis

62
Q

Formula of Risk Nursing Diagnosis

A

Problem Statement + Risk Factors = At Risk/High Risk Nursing Diagnoses

63
Q
  • Are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem
A

Possible Nursing Diagnosis

64
Q
  • The nurse may decide to formulate a tentative or possible nursing diagnosis
A

Possible Nursing Diagnosis

65
Q

Wellness Diagnosis is also known as

A

Health Promotion Diagnosis

66
Q
  • Is a clinical judgment about motivation and desire to increase well-being
A

Wellness Diagnosis

67
Q
  • Concerned in the individual, family or community transition from a specific level of wellness to a higher level of wellness
A

Wellness Diagnosis

68
Q
  • Describes human responses to levels of wellness in an individual
A

Wellness Diagnosis

69
Q
  • Associated with a cluster of other diagnosis
A

Syndrome Diagnosis

70
Q
  • Written as one-part statement requiring only the diagnostic label
A

Syndrome Diagnosis

71
Q
  • The nurse identifies expected outcomes individualized to the patient
A

Outcome Identification

72
Q
  • The nurse analyzes the strengths and weaknesses of the patient, the patient’s family, nursing personnel, the healthcare facility, and the available resources
A

Outcome Identification

73
Q

Activities in the Outcome Identification Phase:

A

Setting Priorities + Establishing Outcomes = Outcome Identification

74
Q

Formula of Outcome Identification

A

Follow Maslow’s hierarchy of basic needs to guide the delivery of care

75
Q

is a measurable, expected, client-focused goal to be achieved at some specified time in the future

A

Outcome

76
Q

In establishing outcomes, it must be:

A

S – specific
M – measurable
A – attainable
R – relevant
T – time bound
E – evaluate
R – reevalute

77
Q

Components of an outcome identification

A

Patient behavior + criteria of performance + conditions (if needed) + time frame = Outcome Statement

78
Q
  • Activity is observable that can be seen, heard, felt or measured by the nurse or reported by the patient
A

Patient Behavior

79
Q
  • Specifies a realistic improvement in functioning in the problem area by a stated time to determine whether the outcome was satisfactorily achieved
A

Criteria of performance

80
Q

The level at which the patient will perform the behavior.

A

Criteria of acceptable behavior

81
Q
  • Outcomes with the patient that require the use or presence of certain environmental conditions
A

Conditions

82
Q
  • The circumstances under which the behavior will be performed
A

Conditions

83
Q

a time or date to clarify to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome

A

Time frame

84
Q
  • Patient can achieve fairly quickly in a matter of hours, in an 8-hour shift, or on daily basis
A

a. Intermediate outcomes (short term)

85
Q
  • Gives direction for nursing care over time. If the patient has alterations in some functions, the long-term outcome is to restore a normal pattern of functioning
A

b. Long term or final outcomes

86
Q
  • The nurse develops a plan of care that prescribes interventions to attain expected outcomes
A

Planning

87
Q

Types of Nursing Interventions

A

Independent
Dependent
Collaborative

88
Q
  • One that nurses are licensed to prescribe or perform based on their knowledge and skills
  • Nurses are accountable for their decisions
A

Independent

89
Q
  • One that is prescribed a physician and carried out by the nurse
A

Dependent

90
Q
  • An interdependent intervention
  • Carried out in collaboration with other health team members (PT, dieticians, physician)
A

Collaborative

91
Q
  • Nurse implements the interventions identified in the plan of care
A

Implementation

92
Q

Implementation Formula:

A

Validation/validating care plan + documenting care plan

93
Q
  • The nurse evaluates the patient’s progress toward attainment of outcomes
  • Result
A

Evaluation

94
Q

occurs continuously which care is being given, shift by shift as nurses evaluate progress toward intermediate outcomes and summatively at discharge

A

Evaluation

95
Q

4 possible judgments that may be made:

A
  • The goal was completely met
  • The goal was partially met
  • The goal was completely unmet
  • Ongoing
96
Q

is a systematic problem solving process that guide all nursing actions. This is the type of thinking and doing that nurses use in their practice (ANA, 2004)

A

Nursing Process

97
Q

What is distinguished as a separate step of nursing process in 1973

A

diagnosis

98
Q

Differentiated as a distinct step of the nursing process

A

Outcome identification

99
Q

Focus of interview

A

establishing rapport
Gather information

100
Q

there are three steps in the diagnosis step:

A
  • Data analysis
  • Problem identification
  • Formulation of nursing diagnosis
101
Q

Two parts of problem statement/diagnostic label

A

QUALIFIERS AND FOCUS

102
Q

Enables the nurse to individualized the client’s care

A

Etiology

103
Q

A clinical judgment concerning with a cluster of problem or risk nursing diagnosis that are predicted to present because of a certain situation or event

A

syndrome diagnosis

104
Q

are those specific activities the nurse plans and implements to help the patient achieve an outcome

A

nursing interventions

105
Q

to appraise the extent to which goals and outcome criteria of nursing care have been achieved

A

Evaluation

106
Q

four distinct activities in the evaluation phase

A

documenting responses to interventions + evaluating effectiveness of interventions + evaluating outcome achievement + reviewing nursing care plan = evaluating

107
Q

is a method for organizing health information in the individual’s record

A

FDAR Focus charting

108
Q

It is a systematic approach to documentation, using nursing terminology to describe individual’s, health status and nursing action

A

Focus charting

109
Q

keyword or diagnostic category from a nursing diagnosis or collaborative problem on the planof care

A

focus

110
Q

An acute change in individuals condition

A

Focus

111
Q

A significant event in an individual’s care

A

focus

112
Q

A keyword or phrase indicating compliance with a standard of care or agency policy

A

Focus

113
Q

subjective or objective information supporting the stated focus or describing observations at the time of significant eventss

A

data

114
Q

nursing interventions performed, plan to be performed, and or protocol and procedures initiated

A

Action

115
Q

Description of individuals response to medical or nursing care

A

Response

116
Q

Statement that the action plan of care outcomes has been attained or are progressing toward attainment

A

response

Health Assessment - RLE (6 decks)

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