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Fundamentals of Nursing Lec > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

Its a systematic problem solving process. Guides all nursing actions.

A

Nursing Process

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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

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3
Q

Its the corner stone of the nursing profession. An essential skill for clinical and application of knowledge and theory

A

Nursing Process

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4
Q

Its synonymous wiht problem solving and its organized, systematic, Goal Oriented, Humanistic Care

A

Nursing Process

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5
Q

This person introduced 3 steps
- note observation
- Administration of care
- Validation

A

Lydia Hall

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6
Q

This person also introduced the 3 steps
- assessment
- decision
- Nursing action

A

Dorothy Johnson

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7
Q

What are the 6 phases of the Nursing Process

A
  1. Assessment
  2. Nursing Diagnosis
  3. Outcome Identification
  4. Plan
  5. Implementation
  6. Evaluation
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8
Q

Identify Phase:
- collects patients health data

A

Assessment

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9
Q

Two types of data

A

subjective and objective data

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10
Q

It is the symptoms or covert data. Verified only by the client

A

Subjective data

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11
Q

This data is only apparent to the one experiencing it.

A

Subjective data

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12
Q

These are the signs or overt data.

A

Objective data

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13
Q

Its the info gathered from physical assessment or tests

A

Objective Data

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14
Q

Data that is measurable and observable

A

Objective Data

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15
Q

What are the two sources of data

A

Primary and Secondary Data

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16
Q

Source of data that can be subjective and objective

A

Primary Data

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17
Q

Name methods of Data Collection

A

Observation and Interview

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18
Q

It is planned communication. Purposeful and structured. Focuses on establishing rapport and gathers data for nursing data base

A

Interview

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19
Q

This phase is based on the data collected in the assessment phase

A

Nursing Diagonosis

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20
Q

This phase identifies problem areas of client after analyzing data collected

A

Nursing Diagnosis

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21
Q

What are the three steps of Nursing Diagnosis Phase

A
  1. Data Analysis
  2. Problem Identification
  3. Formulation of Nursing Diagnosis
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22
Q

Components of Nursing Diagnosis

A
  1. Problem Statement
  2. Etiology
  3. Risk Factor
  4. Defining Characteristics
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23
Q

Component of Nursing Diagnosis:
- describes client health problem or response
- its two parts: qualifiers and ?

A

Problem Statement

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24
Q

It is the words added to some NANDA label to give additional meaning

A

Qualifiers

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25
Q

Qualifier Meaning and its focus
Deficient - ?
Imbalanced - ?
Impaired - ?
Ineffective - ?
Risk For - ?

A

Deficient - Fluid volume
Imbalanced - Nutrition lacking body requirements
Impaired - Gas exchange
Ineffective - Tissue Protection
Risk For - Injury

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26
Q

Component of Nursing Diagnosis:
- Its aka related factors. identifies one or more probable cause of health problems

A

Etiology

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27
Q

Component of Nursing Diagnosis:
- gives direction to required nursing therapy
- enable nurse to individualize client’s care

A

Etiology

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28
Q

Component of Nursing Diagnosis:
- its the conditions involved in development of problem
- Uses phrase related to and linked with problem statement

A

Etiology

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29
Q

Component of Nursing Diagnosis:
- uses phrase “related to”

A

Etiology

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30
Q

Component of Nursing Diagnosis:
- Forces that puts an individual or group at increased vulnerability to unhealthy condition.

A

Risk Factors

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31
Q

Component of Nursing Diagnosis:
- used when etiology not present

A

Risk Factors

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32
Q

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

A

Defining Characteristics

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33
Q

Component of Nursing Diagnosis:
- follows phrase “as evidenced by”

A

Defining Characteristics

34
Q

Types of Nursing Diagnosis

A
  1. Actual Nursing Diagnosis
  2. Risk Nursing Diagnosis
  3. Possible Nursing Diagnosis
  4. Wellness Nursing Diagnosis
  5. Syndrome Nursing Diagnosis
35
Q

Type of Nursing Diagnosis:
Problem identified exists at the present. Based on signs and symptoms

A

Actual Nursing Diagnosis

36
Q

Actual Nursing Diagnosis Formula P.E.SS

A

Patients problem + Etiology + Signs and symptoms

37
Q

Type of Nursing Diagnosis
Problem doesnt exist yet but will likely occur unless nurse intervenes. Requires Clinical Judgement

A

Risk Nursing Diagnosis

38
Q

Formula for Risk Nursing Diagnosis

A

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

39
Q

Type of Nursing Diagnosis:
Its statement describing suspected problem. Its only applicable to newly admitted patients.

A

Possible Nursing Diagnosis

40
Q

Type of Nursing Diagnosis:
Needs further data to validate it

A

Possible Nursing Diagnosis

41
Q

Formula for Possible Nursing Diagnosis

A

Possible + Diagnostic Label

42
Q

Type of Nursing Diagnosis:
- aka health Promotion
- only directed towards healthy individuals

A

Wellness Nursing Diagnosis

43
Q

Type of Nursing Diagnosis:
- clinical judgement about motivation and desire to increase wellness

A

Wellness Nursing diagnosis

44
Q

Formula for Wellness Nursing Diagnosis

A

Health promotion label + as evidence by statement and Defining Characteristics

45
Q

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

A

Syndrome Diagnoses

46
Q

Formula for Syndrome Diagnosis

A

Syndrome diagnosis/Diagnostic Label

47
Q

Third step of the nursing process

A

Outcome Identification

48
Q

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

A

Outcome Identification

49
Q

broad statement about what the client’s state will be after nursing intervention is carried out

A

Client goal is an educated guess

50
Q

written to indicate desired state

A

Behavioral Goals

51
Q

indicate level of performance that needs to be achieved

A

Contains action verb and qualifier

52
Q

Formula for outcome identification

A
  • follows maslow’s hierarchy of basic needs to guide delivery of care
53
Q

SMARTER guidelines for formulating Outcome Identification

A

Specific
Measurable
Attainable
Relevant
Time bound
Evaluate
Reevaluate

54
Q

Formula for Outcome Identification

A

Patient Behavior + Criteria of Performance + Conditions (if needed) + Time Frame

55
Q

activity that can be seen, heard, felt, or measured by the nurse or reported by the patient

A

Patient Behavior

56
Q
  • 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

A

Criterion of performance

57
Q
  • outcomes with the patient that require the use or presence of certain environmental conditions
  • circumstances under which the behavior will be performed
A

Conditions

58
Q

how long it would take to realistically take for the patient to reach level of functioning stated in the criteria part of the outcome

A

Time Frame

59
Q

Time Frame types

A
  • Short Term
  • Long Term
60
Q

Time Frame types
- achieved quickly in matter of hours, in a 8 hrs shift, or daily basis

A

Short term

61
Q

Time Frame types
- gives direction for nursing care over time
- long term outcome is to restore normal pattern of functioning

A

Long Term or Final Outcomes

62
Q

Fourth step of the nursing process

63
Q

This phase prescribes interventions to attain expected outcomes

64
Q

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

A

Nursing Interventions

65
Q

Types of Nursing Interventions

A
  • Independent
  • Dependent
  • Collaborative
66
Q

Types of Nursing Interventions
- nurse licensed to prescribe, perform, or delgate based on their own knowledge and skills
- Nurse accountable for their decisions

A

Independent Nursing Intervention

67
Q

Types of Nursing Interventions
- action is prescribed by a physician and carried out by the nurse

A

Dependent Nursing Intervention

68
Q

Types of Nursing Interventions
- interdependent intervention
- collaboration with other health team members

A

Collaborative

69
Q

Its the fifth step of the nursing process

A

Implementation

70
Q

Step that implements the interventions identified in the plan of care

A

Implementation

71
Q

What is being done during implementation phase?

A

Validating care plan + Documenting care plan + giving and documenting nursing care + continuing data collection = implementing

72
Q

Sixth Step in the Nursing Process

A

Evaluation

73
Q

Step where the nurse evaluates the patient’s progress toward attainment of outcomes

A

Evaluation

74
Q

True or False
- evaluation of patient only happens once

A

False
- occurs continuously

75
Q

Purpose of Evaluating

A

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

76
Q

4 distinct activities in the evaluation phase

A
  1. Documenting Response to Intervention
  2. Evaluating Effectiveness of Intervention
  3. Evaluating Outcome Achievement
  4. Reviewing Nursing Care Plan
77
Q

4 Possible judgements that maybe made

A
  • goal was completely met
  • goal partially met
  • goal was completely unmet
  • ongoing
78
Q
  • 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
A

F-DAR Focus Charting

79
Q

F-DAR stand for…..

A

FOCUS
DATA
ACTION
RESPONSE

80
Q

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

81
Q

F-DAR
- subjective and/or objective information supporting the stated focus or describing observations at the same time of significant events

82
Q

F-DAR
- Nursing interventions performed, planned to be performed, and/or protocols and procedures initiated

Fundamentals of Nursing Lec (11 decks)

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