NURSING PROCESS Flashcards

1
Q

a systematic rationalized method
of planning & providing individualized nursing care.

A

NURSING PROCESS

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2
Q

CLIENT MAY BE;

A
  1. An individual
  2. Family
  3. Community
  4. Group
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3
Q

Data from each phase provide input to next phase

A

CYCLIC & DYNAMIC

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4
Q

Plan of care is according to client’s problems/ needs.

A

CLIENT CENTERED

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5
Q

Communicating with clients, significant others, and support groups.

  • Collaborating with healthcare team
A

Interpersonal and Collaborative

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6
Q
  • Identifying possible solutions and choosing the best one to implement.
  • Approaches include trial and error,intuition, and research.
  • Directed towards client’s responses to real
    or potential disease/ illness.
A

Focus on Problem Solving and Decision Making

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7
Q

Nursing process is used as a framework for nursing care for all types of settings with clients from all age groups.

A

Universal Applicability

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7
Q
  • Making clinical judgements based on knowledge base in nursing and clinical experience.
A

Use of Critical Thinking and Clinical Reasoning

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8
Q

Assessing all viewpoints and
avoiding biases or prejudice.

A

FAIR MINDEDNESS

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8
Q

Thinking for yourself and making
your own judgements.

A

INDEPENCE

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9
Q

Awareness of the limits of
one’s own knowledge

A

INTELLECTUAL HUMILITY

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9
Q

Examining one’s own
biases or customs; Self-awareness.

A

INSIGHT & EGOCENTRICITY

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10
Q

Being able to readily admit and
evaluate inconsistencies with and between one’s
belief and those of another

A

INTEGRITY

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10
Q

Courage to recognize that beliefs
are sometime false or misleading. Courage to be
open to new thinking.

A

Intellectual Courage to Challenge Status Quo and Rituals

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11
Q

in the reasoning
process and examining emotion ladenarguments. Anchored on the belief that wellreasoned thinking will lead to trustworthy
conclusions.

A

CONFIDENCE

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11
Q

Lifelong determination in finding
effective solutions to client and nursing problems

A

PERSEVERANCE

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12
Q

Examining traditions and exploring new options

A

CURIOSITY

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13
Q

Determining which is most
relevant and most important.

A

SETTING PRIORITIES

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13
Q

Explanations of priority
setting and nursing interventions.

Acts as a check for potential errors, justifies nursing actions and contributes to client safety.

A

DEVELOPING RATIONALE

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14
Q
  • Understanding relevant
    medical and nursing information and translate knowledge into plan of care.
A

Learning How to Act

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15
Q

Ability to recognize changes in client’s condition over time

A

Clinical Reasoning in Transition

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16
Q

Ability to detect changes, identify change in priorities, adjust nursing care and alert primary
care provider when appropriate.

A

Responding to Changesin the Client’s Condition

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17
Q

Identifying factors that improved
client care and those thaT required changing or
elimination.

  • Thinking back / Reviewing interventions implemented and whether they were effective.
A

REFLECTION

18
Q

Gather information about the
patient’s condition.

A

ASSESSMENT

18
Identify the patient’s problems.
DIAGNOSIS
18
Set goals of care and desired outcomes and identify appropriate nursing actions
PLANNING
19
Perform the nursing actions identified in planning
IMPLEMENTATION
20
Determine if goals and expected outcomes are achieved.
EVALUATION
21
TYPES OF ASSESSMENTS:
1. Initial Assessment 2. Problem-Focused Assessment 3. Emergency Assessment 4. Time-Lapsed Assessment
22
Performed within a specified time after admission to a health care agency Purpose: to establish a complete database problem identification, reference and future comparison
INITIAL ASSESSMENT
23
Ongoing process integrated with nursing care. Purpose: to determine the status of a specific problem identified in an earlier assessment
PROBLEM - FOCUSED ASSESSMENT
24
Done during any physiological or psychological crisis of the client. Purpose: to identify life-threatening problems / To identify new or overlooked problems
EMERGENCY ASSESSMENT
25
26
– Done several months after initial assessment. Purpose: to compare the client’s current status to baseline data previously obtained
TIME LAPSED ASSESSMENT
27
is the process of gathering information about a client’s health status
DATA COLLECTION
28
contains all the information of the client. Includes nursing health history, physical assessment, primary care provider’s history and physical examination, results of laboratory and diagnostic tests and materials contributed by other health personnel. - Client data should include past history and current problems.
DATABASE
29
2 TYPES OF DATA
SUBJECTIVE & OBJECTIVE
30
o Symptoms or covert data (unseen) o Can be described or verified only by that person. o Sensations, feelings, values, beliefs, attitudes, perceptions of personal health status and life situation
SUBJECTIVE DATA
31
o Signs or overt data (seen) o Detectable by an observer or can be measured or tested against an accepted standard. o Obtained by observation or physical examination.
OBJECTIVE DATA
32
Occurs whenever the nurse is in contact with the client or support persons.
OBSERVING
33
Used mainly when taking the nursing health history.
INTERVIEWING
34
– a planned communication; a conversation with a purpose
INTERVIEW
35
- the nurse asks the client
FOCUSED INTERVIEW
36
* Highly structured and elicits specific information * The nurse establishes the purpose of the interview and controls the interview * Client may have limited opportunity to ask questions or discuss concerns * Usually used when time is limited (e.g. emergency situation)
DIRECTIVE INTERVIEW
37
* Also known as rapport-building interview * Allows the client to control the purpose, subject matter and pacing
NON - DIRECTIVE INTERVIEW
38
-Used in directive interview -Yes or No Questions -What, When, Where, Who, Do, Did, Does, Is, Are, Was, Were questions -Often used when information is needed quickly
CLOSED QUESTION
39
-Used in non-directive interview\ -Invite clients to discover, explore, elaborate, clarify, or illustrate their thoughts -What and How -Gives clients freedom to divulge only the information they are ready to disclose
OPEN ENDED QUESTION
40
– Closed. Directs client’s answer and gives less opportunity to decide whether the answer is true or not. May create problems if client gives inaccurate answers to please the nurse.
LEADING
40
questions that client can answer without pressure. Open-ended and nondirective.
NEUTRAL QUESTION
41
– Client communicates what they think, feel, know, and perceive in response to questions from the nurse.
BODY
41
– Establish rapport and orient the purpose and flow of interview.
OPENING
42
Offer to answer questions. Conclude and provide the summary to verify accuracy and agreement. Thank the client and express concern for their welfare. Plan the next meeting ahead.
CLOSING
43
Major method used in physical examination or physical assessment.
EXAMINING
44
data collection that uses observation to detect health problems
SYSTEMATIC
45
Techniques used in examination: ▪ I ▪ A ▪ P ▪ P
▪ INSPECTION ▪ AUSCULATION ▪ PALPATION ▪ PERCUSSION