Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

NURS 402: Lecture > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

What are the purposes of the diagnosing step in the Nursing Process?

A
  1. Identify how an individual, group, or community responds to actual or potential health and life processes
  2. Identify factors that contribute to, or cause, health problems (etiologies)
  3. Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Patient Problems Statements focuse on what?

A

Problem statements focus on unhealthy responses to health and illness; may change from day to day as the patient’s responses change

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Medical Diagnosis identifies what?

A

Identifies diseases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Medical Diagnosis describes what?

A

describe problems for which the physician or advanced practice nurses directs the primary treatment;

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Does the medical diagnosis change?

A

remains the same for as long as the disease is present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Diagnostic Reasoning, Clinical Reasoning, and Clinical Judgment- how to?

A

Be familiar with lists of actual and potential problems and needs; read professional literature and keep reference guides handy

Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide

Respect your clinical intuition, but before writing a problem statement without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition

Recognize personal biases and keep an open mind

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Steps of Data Interpretation and Analysis

A

Recognizing significant data: Comparing data to standards

Recognizing patterns or clusters

Identifying strengths and current or potential problems

Identifying potential complications

Reaching conclusions

Partnering with the patient and family

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Types of Nursing Diagnoses

A

Problem-focused
Risk
Health promotion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Formulation of Nursing Diagnoses

A

Problem

Etiology

Signs and Symptoms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is ‘Problem’ in the Formulation of Nursing Diagnoses?

A

Identifies what is unhealthy about patients

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is ‘Etiology’ in the Formulation of Nursing Diagnoses?

A

Identifies factors maintaining the unhealthy state

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Goal of Outcome Identification and Planning Step

A

Establish priorities

Identify and write expected patient outcomes

Select evidence-based nursing interventions

Communicate the nursing plan of care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

A Formal Care Plan Allows the Nurse to:

A

Individualize care that maximizes outcome achievement

Set priorities

Facilitate communication among nursing personnel and colleagues

Promote continuity of high-quality, cost-effective care

Coordinate care

Evaluate patient response to nursing care

Create a record used for evaluation, research, reimbursement, and legal reasons

Promote nurse’s professional development

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What should you be familiar with?

A

Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What is the goal?

A

Remember that the goal of thoughtful, patient-centered practice is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What is the ‘big picture’ focus?

A

Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Outcome Identification, Planning, and Clinical Reasoning #2

A

Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice

Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan

Recognize your personal biases and keep an open mind

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Three Elements of Comprehensive Planning

A
  1. Initial
  2. Ongoing
  3. Discharge
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Initial Planning- who is it developed by?

A

Developed by the nurse who performs the nursing history and physical assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Initial Planning- what does it address?

A

Addresses each problem listed in the prioritized problem list

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Initial Planning -identifies what?

A

Identifies appropriate patient goals and related nursing care

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Ongoing planning- who is it carried out by?

A

Carried out by any nurse who interacts with patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Ongoing planning- what does it do to the plan?

A

Keeps the plan up to date, manages risk factors, promotes function

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Ongoing planning- what does it have to do with problem statements?

A

States problem statements more clearly

Develops new problem statements

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Ongoing planning- what does it do to the outcomes and nursing interventions?
Makes outcomes more realistic and develops new outcomes as needed Identifies nursing interventions to accomplish patient goals
26
Discharge Planning- who is it carried out by?
Carried out by the nurse who worked most closely with the patient
27
Discharge Planning- when does it begin?
Begins when the patient is admitted for treatment
28
Discharge planning: what does it use?
Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently
29
What is the first part of the nursing diagnosis? (problem statement)
Identifies the unhealthy response Indicates what should change
30
What does the first part of the nursing diagnosis LEAD to?
Suggests patient goals/outcomes (expectations for change)
31
What is the second part of the nursing diagnosis? (etiology)
Identifies factors causing or contributing to the undesirable response and preventing desired change.
32
What is the second part of the nursing diagnosis? (etiology) lead to?
Suggests nursing interventions
33
What are the priorities that need to be established?
Maslow's hierarchy of human needs Patient preference Anticipation of future problems Critical thinking/clinical reasoning and judgement
34
Maslow's hierarchy of human needs
Physiologic needs Safety needs Love and belonging needs Self-esteem needs Self-actualization needs
35
Clinical Reasoning and Establishing Priorities #1
What problems need immediate attention and which ones can wait? Which problems are the responsibility of the nurse and which need to be referred to someone else? Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)? Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?
36
Clinical Reasoning and Establishing Priorities #2
Have changes in the patient’s health status influenced the priority of nursing diagnoses/problems? Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses/problems that can be realistically addressed? Are there relationships among diagnoses/problems that require that one be worked on before another can be resolved? Can several patient problems be dealt with together?
37
Categories of Outcomes
Cognitive: Psychomotor: Affective:
38
Categories of Outcomes: Cognitive
describes increases in patient knowledge or intellectual behaviors
39
Categories of Outcomes: Psychomotor
describes patient’s achievement of new skills
40
Categories of Outcomes: Affective
describes changes in patient values, beliefs, and attitudes
41
Clinical outcomes
Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved
42
Functional outcomes
Functional outcomes describe the person’s ability to function in relation to the desired usual activities
43
Quality-of-life outcomes
Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals
44
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care
Safe: Effective: Patient-centered: Timely: Efficient: Equitable:
45
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: SAFE
Safe: avoiding injury
46
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFECTIVE
Effective: avoiding overuse and underuse
47
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: Patient-centered
Patient-centered: responding to patient preferences, needs, and values
48
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: TIMELY
Timely: reducing waits and delays
49
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFICIENT
Efficient: avoiding waste
50
IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EQUITABLE
Equitable: providing care that does not vary in quality to all recipients
51
Joint Commission National Patient Safety Goals (7 Goals)
Identify patients correctly Improve staff communication Use medicines safely Use alarms safely Prevent infection Identify patient safety risks Prevent mistakes in surgery
52
Types of Nursing Interventions
Nurse-initiated: Physician-initiated: Collaborative:
53
Types of Nursing Interventions: Nurse Initiated
Nurse-initiated: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes
54
Types of Nursing Interventions: Physician initiated
Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders
55
Types of Nursing Interventions: Collaborative
Collaborative: treatments initiated by other providers and carried out by a nurse
56
Structured Care Methodologies
Procedure: Standard of care: Algorithm: Clinical practice guideline:
57
Structured Care Methodologies: Procedure
Procedure: set of how-to action steps
58
Structured Care Methodologies: Standard of care:
Standard of care: description of acceptable level of patient care
59
Structured Care Methodologies: Algorithm:
Algorithm: set of steps used to make a decision
60
Structured Care Methodologies: Clinical practice guideline
Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure
61
Formats of Care Plans
Computerized care plans Concept map care plans Change of shift reports Multidisciplinary (collaborative) care plans Student care plans
62
Purposes of Implementation
Help the patient achieve valued health outcomes Promote health Prevent disease and illness Restore health Facilitate coping with altered functioning
63
Focus of Nursing Implementation
Scope of Practice: Who, what, where, when, and why Nursing interventions taxonomy structure Care coordination and continuity
64
Types of Nursing Interventions
Those providing direct and indirect care Independent and collaborative interventions Protocols and standing orders Care bundles
65
Implementing Guidelines #1
Act in partnership with the patient/family Before implementing, reassess the patient to determine whether the action is still needed Approach the patient competently Approach the patient caringly Modify nursing interventions according to specific criteria.
66
You modify nursing interventions according to what?
1. Developmental and psychosocial background 2. ability and willingness to participate in the care plan 3. responses to previous nursing measures and progress toward goal/outcome achievement
67
Implementing the Plan of Care #1
Determine the patient’s new or continuing need for assistance Promote self-care Assist the patient to achieve valued health outcomes Reassess the patient and review the plan of care Use patient boards or whiteboards Plan ahead and organize resources Clarify prerequisite nursing competencies
68
Implementing the Plan of Care #2
Anticipate unexpected outcomes and solutions Ensure quality and patient safety Promote self-care: teaching, counseling, and advocacy Assist patients to meet health outcomes
69
Reassessing the Patient and Reviewing the Care Plan
Be sure that each nursing intervention is supported by a sound scientific rationale, as demanded by an evidence-based practice Be sure that each nursing intervention is consistent with professional standards of care and consistent with the protocols, policies, and procedures of the institution or agency Be sure that the nursing actions are safe for this particular patient and individualized to the patient’s preferences Clarify any questionable orders
70
Variables Influencing Outcome Achievement
Patient variables Nurse variables
71
Variables Influencing Outcome Achievement: Patient variables
Developmental stage Psychosocial background and culture
72
Variables Influencing Outcome Achievement: Nurse variables
Resources Scope of practice and current standards of care Research findings Ethical and legal guides to practice
73
Common Reasons for Noncompliance
Lack of family support Lack of understanding about the benefits Low value attached to outcomes Adverse physical or emotional effects of treatment Inability to afford treatment Limited access to treatment
74
Five Rights of Delegation
1. Right Task 2. Right Circumstances 3. Right person 4. Right directions and communication 5. Right supervision and evaluation
75
During evaluation what does the Nurse and patient do together?
Nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan
76
During evaluation, what does the nurse identify?
The nurse identifies factors that contribute to the patient's ability to achieve expected outcomes and, when necessary, modifies the plan of care
77
What is the purpose of evaluation?
The purpose of evaluation is to allow the patient's achievement of expected outcomes to direct future nurse-patient interactions
78
Five Classic Elements of Evaluation:
1. Identifying evaluative criteria and standards 2. Collecting data to determine whether criteria and standards are met 3. Interpreting and summarizing findings 4. Documenting judgment 5. Terminating, continuing, or modifying the plan
79
Evaluating outcome: what do you evaluate?
Cognitive: Psychomotor: Affective: Physiologic:
80
Evaluating outcome: what do you evaluate?Cognitive
Cognitive: asking patient to repeat information or apply new knowledge
81
Evaluating outcome: what do you evaluate? Psychomotor
Psychomotor: asking patient to demonstrate new skill
82
Evaluating outcome: what do you evaluate? Affective
Affective: observing patient behavior and conversation
83
Evaluating outcome: what do you evaluate? Physiologic
Physiologic: using physical assessment skill to collect and compare data
84
Variables Affecting Outcome Achievement
Patient Nurse Health care system
85
Variables Affecting Outcome Achievement: Patient example
For example, a patient gives up and refuses treatment
86
Variables Affecting Outcome Achievement: Nurse example
For example, a nurse is suffering from burnout
87
Variables Affecting Outcome Achievement: Health care system
For example, inadequate staffing
88
Actions Based on Patient Response to Care Plan
Delete or modify the diagnosis/problem Make the outcome statement more realistic Ime criteria in outcome statement Change nursing interventions
89
Seven Crucial Conversations in Health Care
Broken rules Mistakes Lack of support Incompetence Poor teamwork Disrespect Micromanagement
90
Documentation
Written or electronic legal record of all pertinent interactions with the patient Includes data related to assessing, diagnosing, planning, implementing, and evaluating Facilitates quality, evidence-based patient care Serves as financial and legal record Helps in clinical research Supports decision analysis
91
Elements of Documentation
Content Timing Format Accountability Confidentiality
92
What Is Confidential?
All information about patients written on paper, spoken aloud, saved on computer
93
What Is Confidential? Examples
Name, address, phone, fax, social security number Reason the person is sick Treatments patient receives Information about past health conditions
94
Potential Breaches in Patient Confidentiality
Displaying information on a public screen Sending confidential e-mail messages via public networks Sharing printers among units with differing functions Discarding copies of patient information in trash cans Holding conversations that can be overheard Faxing confidential information to unauthorized persons Sending confidential messages overheard on pagers
95
Patient Rights
Patients have the right to: See and copy their health record Update their health record Get a list of disclosures Request a restriction on certain uses or disclosures Choose how to receive health information
96
Policy for Receiving Verbal Orders
Must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist Record the orders in patient’s medical record with the initials VO Read back the order to verify accuracy Date and note the time orders were issued Record verbal order and name of the physician or NP issuing the order, followed by nurse’s name and initials Should be limited to urgent situations
97
Methods of Documentation
Computerized documentation/Electronic health records (EHRs) Source-Oriented Records Problem-Oriented Medical Records PIE Charting: Problem, Intervention, Evaluation Focus Charting Charting by Exception
98
Source-Oriented Records include
Progress notes; narrative notes
99
Problem-Oriented Medical Records include
SOAP notes
100
Formats for Nursing Documentation
Initial nursing assessment Care plan; patient care summary Critical collaborative pathways Progress notes Flow sheets and graphic records Medication administration record Acuity record Discharge and transfer summary Home health care documentation Long-Term care documentation
101
Reporting Care or Requesting Action
Change of Shift/Handoff Report ISBARR Telephone/Telemedicine Report Transfer and Discharge Reports Reports to Family Members or Significant Others Incident/Variance Reports
102
Hand-off Communication/ISBARR
Identity/Introduction Situation Background Assessment Recommendation Read back of orders/response
103
Change of Shift/Hand-off Reports
Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians Current appraisal of each patient’s health status Current orders (especially any newly changed orders) Abnormal occurrences during your shift Any unfilled orders that need to be continued onto the next shift Patient/family questions, concerns, needs Reports on transfers/discharges
104
Telephone/Telemedicine Reports
Identify yourself and the patient, and state your relationship to the patient Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this condition Report the patient’s current vital signs and clinical manifestations Have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries Concisely record time and date of the call, what was communicated, and physician’s response
105
Conferring about Care
Consultations and referrals Nursing and interdisciplinary team care conferences Nursing care rounds Purposeful rounding
106
Eight Behaviors of Purposeful Rounding
Use Opening Key Words (C-I-CARE) with PRESENCE Accomplish scheduled tasks Address four Ps Address additional personal needs, questions Conduct environmental assessment Ask “Is there anything else I can do for you? I have time.” Tell the patient when you will be back Document the round

NURS 402: Lecture (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions