Nursing Process Flashcards
1
Q
Its a systematic problem solving process. Guides all nursing actions.
A
Nursing Process
2
Q
Type of thinking and doing of nurses. Requires Critical Thinking to apply best caregiving and promoting human functions and responses
A
Nursing Process
3
Q
Its the corner stone of the nursing profession. An essential skill for clinical and application of knowledge and theory
A
Nursing Process
4
Q
Its synonymous wiht problem solving and its organized, systematic, Goal Oriented, Humanistic Care
A
Nursing Process
5
Q
This person introduced 3 steps
- note observation
- Administration of care
- Validation
A
Lydia Hall
6
Q
This person also introduced the 3 steps
- assessment
- decision
- Nursing action
A
Dorothy Johnson
7
Q
What are the 6 phases of the Nursing Process
A
- Assessment
- Nursing Diagnosis
- Outcome Identification
- Plan
- Implementation
- Evaluation
8
Q
Identify Phase:
- collects patients health data
A
Assessment
9
Q
Two types of data
A
subjective and objective data
10
Q
It is the symptoms or covert data. Verified only by the client
A
Subjective data
11
Q
This data is only apparent to the one experiencing it.
A
Subjective data
12
Q
These are the signs or overt data.
A
Objective data
13
Q
Its the info gathered from physical assessment or tests
A
Objective Data
14
Q
Data that is measurable and observable
A
Objective Data
15
Q
What are the two sources of data
A
Primary and Secondary Data
16
Q
Source of data that can be subjective and objective
A
Primary Data
17
Q
Name methods of Data Collection
A
Observation and Interview
18
Q
It is planned communication. Purposeful and structured. Focuses on establishing rapport and gathers data for nursing data base
A
Interview
19
Q
This phase is based on the data collected in the assessment phase
A
Nursing Diagonosis
20
Q
This phase identifies problem areas of client after analyzing data collected
A
Nursing Diagnosis
21
Q
What are the three steps of Nursing Diagnosis Phase
A
- Data Analysis
- Problem Identification
- Formulation of Nursing Diagnosis
22
Q
Components of Nursing Diagnosis
A
- Problem Statement
- Etiology
- Risk Factor
- Defining Characteristics
23
Q
Component of Nursing Diagnosis:
- describes client health problem or response
- its two parts: qualifiers and ?
A
Problem Statement
24
Q
It is the words added to some NANDA label to give additional meaning
A
Qualifiers
25
Qualifier Meaning and its focus
Deficient - ?
Imbalanced - ?
Impaired - ?
Ineffective - ?
Risk For - ?
Deficient - Fluid volume
Imbalanced - Nutrition lacking body requirements
Impaired - Gas exchange
Ineffective - Tissue Protection
Risk For - Injury
26
Component of Nursing Diagnosis:
- Its aka related factors. identifies one or more probable cause of health problems
Etiology
27
Component of Nursing Diagnosis:
- gives direction to required nursing therapy
- enable nurse to individualize client's care
Etiology
28
Component of Nursing Diagnosis:
- its the conditions involved in development of problem
- Uses phrase related to and linked with problem statement
Etiology
29
Component of Nursing Diagnosis:
- uses phrase "related to"
Etiology
30
Component of Nursing Diagnosis:
- Forces that puts an individual or group at increased vulnerability to unhealthy condition.
Risk Factors
31
Component of Nursing Diagnosis:
- used when etiology not present
Risk Factors
32
Component of Nursing Diagnosis:
- clusters of sign and symptoms
- when used in actual nursing diagnosis : identifies signs and symptoms of client
- when used in risk nursing diagnosis: no signs and symptoms present
Defining Characteristics
33
Component of Nursing Diagnosis:
- follows phrase "as evidenced by"
Defining Characteristics
34
Types of Nursing Diagnosis
1. Actual Nursing Diagnosis
2. Risk Nursing Diagnosis
3. Possible Nursing Diagnosis
4. Wellness Nursing Diagnosis
5. Syndrome Nursing Diagnosis
35
Type of Nursing Diagnosis:
Problem identified exists at the present. Based on signs and symptoms
Actual Nursing Diagnosis
36
Actual Nursing Diagnosis Formula P.E.SS
Patients problem + Etiology + Signs and symptoms
37
Type of Nursing Diagnosis
Problem doesnt exist yet but will likely occur unless nurse intervenes. Requires Clinical Judgement
Risk Nursing Diagnosis
38
Formula for Risk Nursing Diagnosis
Problem Statement + Risk Factors = At Risk/ High Risk Nursing Diagnosis
39
Type of Nursing Diagnosis:
Its statement describing suspected problem. Its only applicable to newly admitted patients.
Possible Nursing Diagnosis
40
Type of Nursing Diagnosis:
Needs further data to validate it
Possible Nursing Diagnosis
41
Formula for Possible Nursing Diagnosis
Possible + Diagnostic Label
42
Type of Nursing Diagnosis:
- aka health Promotion
- only directed towards healthy individuals
Wellness Nursing Diagnosis
43
Type of Nursing Diagnosis:
- clinical judgement about motivation and desire to increase wellness
Wellness Nursing diagnosis
44
Formula for Wellness Nursing Diagnosis
Health promotion label + as evidence by statement and Defining Characteristics
45
Type of Nursing Diagnosis:
- associated with a cluster of other diagnoses
- clinical judgement concerning with a cluster of problem or risk nursing diagnoses that predicted to present because of certain situation or event
Syndrome Diagnoses
46
Formula for Syndrome Diagnosis
Syndrome diagnosis/Diagnostic Label
47
Third step of the nursing process
Outcome Identification
48
Type of Nursing Diagnosis:
- identifies expected outcomes individualized to the patient
- analyses strength and weaknesses of the patient, patient's family, nursing personnel, healthcare facility and available resources
Outcome Identification
49
broad statement about what the client's state will be after nursing intervention is carried out
Client goal is an educated guess
50
written to indicate desired state
Behavioral Goals
51
indicate level of performance that needs to be achieved
Contains action verb and qualifier
52
Formula for outcome identification
- follows maslow's hierarchy of basic needs to guide delivery of care
53
SMARTER guidelines for formulating Outcome Identification
Specific
Measurable
Attainable
Relevant
Time bound
Evaluate
Reevaluate
54
Formula for Outcome Identification
Patient Behavior + Criteria of Performance + Conditions (if needed) + Time Frame
55
activity that can be seen, heard, felt, or measured by the nurse or reported by the patient
Patient Behavior
56
- specifies realistic improvement in functioning in problem area by a stated time to determine whether outcome was satisfactorily achieved
answers question how well, how far, and how much
Criterion of performance
57
- outcomes with the patient that require the use or presence of certain environmental conditions
- circumstances under which the behavior will be performed
Conditions
58
how long it would take to realistically take for the patient to reach level of functioning stated in the criteria part of the outcome
Time Frame
59
Time Frame types
- Short Term
- Long Term
60
Time Frame types
- achieved quickly in matter of hours, in a 8 hrs shift, or daily basis
Short term
61
Time Frame types
- gives direction for nursing care over time
- long term outcome is to restore normal pattern of functioning
Long Term or Final Outcomes
62
Fourth step of the nursing process
Planning
63
This phase prescribes interventions to attain expected outcomes
Planning
64
They are the specific activities the nurse plans and implements to help the patient achieve an outcome
Nursing Interventions
65
Types of Nursing Interventions
- Independent
- Dependent
- Collaborative
66
Types of Nursing Interventions
- nurse licensed to prescribe, perform, or delgate based on their own knowledge and skills
- Nurse accountable for their decisions
Independent Nursing Intervention
67
Types of Nursing Interventions
- action is prescribed by a physician and carried out by the nurse
Dependent Nursing Intervention
68
Types of Nursing Interventions
- interdependent intervention
- collaboration with other health team members
Collaborative
69
Its the fifth step of the nursing process
Implementation
70
Step that implements the interventions identified in the plan of care
Implementation
71
What is being done during implementation phase?
Validating care plan + Documenting care plan + giving and documenting nursing care + continuing data collection = implementing
72
Sixth Step in the Nursing Process
Evaluation
73
Step where the nurse evaluates the patient's progress toward attainment of outcomes
Evaluation
74
True or False
- evaluation of patient only happens once
False
- occurs continuously
75
Purpose of Evaluating
appraise the extent which goals and outcome criteria of nursing care have been achieved
76
4 distinct activities in the evaluation phase
1. Documenting Response to Intervention
2. Evaluating Effectiveness of Intervention
3. Evaluating Outcome Achievement
4. Reviewing Nursing Care Plan
77
4 Possible judgements that maybe made
- goal was completely met
- goal partially met
- goal was completely unmet
- ongoing
78
- Method of organizing health information in individual's records
- systematic approach to documentation
- uses nursing terminology to describe individual's health status and nursing action
F-DAR Focus Charting
79
F-DAR stand for.....
FOCUS
DATA
ACTION
RESPONSE
80
F-DAR
- acute change in individual's condition
- significant event in individual's care
- key word or phrase indicating comliance with a standar of care or agency policy
FOCUS
81
F-DAR
- subjective and/or objective information supporting the stated focus or describing observations at the same time of significant events
DATA
82
F-DAR
- Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated
ACTION
