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N125 Exam 1 Study guide > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

What is the nursing process ?

A

A framework nurses use to apply critical thinking in nursing practice for making clinical decisions

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2
Q

What are the 5 components of ADPIE ?

A

-Assessment (subjective & objetive data)
-Diagnosis (actual vs at risk, i.e do not use medical diagnosis terms to describe)
-Planning (proctorize goals & expected outcomes)
-Implementation (standardized nursing interventions)
Evaluation (

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3
Q

Describe Assessment

A

-The first thing nurses always do is assess the patient/client
-This is conducted during physical examination

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4
Q

What are the 2 types of assessments ?

A

-Patient-centered interview+physical exam
-Periodic assessments+physcial exam

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5
Q

What is a comprehensive assessment ?

A

A full head-to-toe assessment

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6
Q

What is a focused assessment ?

A

-A more targeted assessment of the are of concern
-Ask any questions related to that are of pain
-Specifically focusing on what the patient came in complaining about

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7
Q

Describe data being gathered when assessing a patient.

A

Consists of patient’s perceived needs, health problems, and responses to problems

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8
Q

What are the two types of data ?

A

-Subjective data
-Objective data

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9
Q

Describe subjective data

A

-The pt’s verbal description of their health problems gathered during interviews (informal+formal)
-Includes the pt’s feelings, perceptions, and self-reported symptoms
-Often reflect physiological, social, or psychological changes
*Example: pt says “Feels like an elepahnt is sitting on my chest”
-Pain is subjective

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10
Q

Describe Objective data

A

-The findings resulting from observation of the pt’s behavior and clinical signs and direct measurements
The data we can measure or observe in out pt
*Example: Vital signs, lab data,BP

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11
Q

What are sources of data ?

A

-Primarily from the pt, family, medical records, and diagnostic lab data
-We’re always comparing data with the normal limits

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12
Q

What are the 4 methods of assessment ?

A
  1. Patient-centered interview
  2. Nurse’s experience
  3. Environment
    4.Nursing Health History
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13
Q

Explain the Patient-centered interview method

A

-Relationship-based and organized conversation focused in learning about a pt’s concerns and needs
-Where you develop a rapport, ask open-ended questions, and develop relationship with the pt

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14
Q

Explain the Nurse’s experience method

A

-Can be dependent on the level of experience for the nurse
-Provides a background for each clinical encounter with a pt
-Reflect on personal experience to help you explore a pt’s situation
-Experience in caring for pt’t is an important source of data
-As a new nurse, use systematic and analytical method for assessment
-Experience with nursing skills as important for an accurate assessment

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15
Q

Explain the Environment method

A

-Consider the setting where you perform an assessment
-Use each pt encounter as a time to perform assessment and focus on the pt priorities

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16
Q

Explain the Nursing Health History method

A

-Important to conduct a thorough health history
-Ask the right questions
-Ask th ept to explain why thye came for health care, listen, proceed at reasonable pace, and ask open-ended questions

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17
Q

What are the components of the nursing healthy history ?

A

-Present illness or health concerns (PQRST)
-Use PQRST to guide your assessment
-Data documentation

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18
Q

What does PQRST mean ?

A

P-provokes
Q-quality
R-radiate
S-severity
T-time

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19
Q

Concept Mapping

A

Apart of the assessment process
-A visual representation that allows nurses to graphically illustrate the connections between a pt’s health problems
-Allows nurses to obtain hollistic perspective of health care needs

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20
Q

Explain Data Documentation

A

-With all the info and findings collected, we document into the pt’s medical record
-The last component of the assessement
-Legal and professional responsibility
-Requires accurate+approved terminology+abbrevations

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21
Q

Describe Diagnosis

A

After we assess, we develop a nursing diagnosis

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22
Q

What is data clustering ?

A

-Sets of assessment findings/defining characteristics
-A group of data elements, the signs or symptoms gathered during assessment
-Identifying pt’s problems from a nursing perspective
-Organize data
-Look for meaningful patterns

23
Q

What is the nursing diagnosis (dx) ?

A

-A clincal judgment in response in repsonse to a pt’s potential helath problem (not a medical dx (what physicians do)
-Identifying a problem nurses can manage
*Ex: “Impaired comfort r/t itching”, “risk for electrolyte imbalance r/t renal dysfunction”, “disturbed body image r/t lesions on body”, “deficient fluid volume r/t active fluid loss as evidence by(aeb) excessive diuresis”

24
Q

Proper Nurse Dx

A

-Must have a r/t statement
-If evidence exist add “aeb” (as evidence by)
ex:Deficient fluid volume r/t active fluid loss aeb excessive diuresis

25
Q

Data interpretation

A

-Look for defining characteristics )assessment findings)
-Signs and symptoms that supprot identifying the pt’s problem freom a nursing perspective

26
Q

Nurse’s independent practice

A

-North American Nursing Dx Association (NANDA-I)
-Ex: Symptom relief and client education
-Use a common language to unde the pt’s needs

27
Q

What are the 3 types of nursing dx ?

A

-Actual (Problem focused) nuring dx
-Risk nursing dx
-Health promotion/Pt education nursing dx

28
Q

Explain Actual (problem focused) nursing dx

A

-Describes undesirable human responses to existing problems or concerns of a pt
Ex: a pt has a tissue injury on their butt, so they developed a pressure ulcer because they’ve been in bed for 3 weeks

29
Q

Explain Risk nursing dx

A

-Describe human responses to health conditions.life processes that may develop
Ex: A pt just came out of surgery, their skin is intact, but they are at risk for tissue injury because they will be immobile due to their surgery

30
Q

What are the components of a nursing dx ?

A

-Diagnostice label or dx
-Related factors (r/t)
-Definition (NANDA-I)
-Associated condition
-Support of the diagnostic statement

31
Q

Describe planning step in the nursing process

A

-After we assess and develop a nursing dx, the next step is to plan our outcomes
-Based on priority

32
Q

Classification of priorities

A

-High
-Intermediate
-Low
Maslow’s Hierarchy of needs
-ABC’s (first priority)
Airway
Breathing
Circulation

33
Q

What are Maslow’s Hierchy of Needs ?

A
  1. Self Actualization
  2. Esteem Needs
  3. Social Needs
  4. Safety needs
  5. Physiological Needs
    *In an acute care setting, emphasis is to meet the pt’s physiological and safety needs
34
Q

What are the Nursing Outcomes Classifications (NOC) ?

A

SMART ACRONYM
S-specific
M-measurable
A-attainable
R-realistic
T-timed

35
Q

Planning outcomes include 3 types of interventions, name them

A

-Nurse-initiated
-Health care provider-initiated
-Collaborative

36
Q

Explain Nurse-initiated intervention

A

-Independent in nursing intervention where a nurse initiiated in response to a nursing dx without supervision/direction
Ex: Moving a pt up and down in the bed, getting them comfortable

37
Q

Explain Health care provider-initiated intervention

A

-Dependent nursing intervention that requires order from a health care provider
Ex: Administering pain medication

38
Q

Explain Collaborative intevention

A

-Interdependent interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care providers
Ex: Collaborating with a dietitian or PT on how to manage a pt’s situation

39
Q

What are the 3 planning nurse care plans ?

A

-Nursing care plans
-Interprofessional care plans
-Concept maps

40
Q

Explain Nurisng care plan

A

-Includes the nursing dx, expected outcomes, individualized nursing interventions, and evaluation findings

41
Q

Explain Interprofessional care plans

A

-Contributions from all nurses, providers, other health professionals involved in pt care

42
Q

Explain concept maps

A

-Students
-Visual representation of all of a pt’s dx with diagram interventions for each

43
Q

Describe Implementation in the nursing process

A

-Next we implement the nursing care
-This step begins after a pt’s plan of care
-Before you implement, REASSESS
-Review the set of all possible nursing interventions
-Review all possible consequences associated with each possible nursing action
-Determine the probability of all possible consequences
Make a judgment of the value of that consequence to the pt

44
Q

Explain standard nursing interventions

A

-Allow nurses to deliver the most clinically effective care to improve pt outcomes
-Captures pt care info that can be shared across care settings
-Based on pt’s individual needs+ preferences
-Using a common language

45
Q

What are the 3 interventons included in the implementation step in the nursing process ?

A

-Clinical practice guidelines+protocols
-Standing orders
-Nursing intervention classification

46
Q

Explain clinical practice guidelines + protocols

A

-One form is a care bundle
-Group of interventions related to a disease process/condition

47
Q

Explain standing orders

A

Preprinted documents containing medical orders for rountine therapies, monitoring guidelines, and diagnostic procedures for specific pts with identified clincal problems

48
Q

Explain Nurisng Intervention Classification (NIC)

A

Using standardized language nurses can use to identify treatments they perform, organize info, and provide a language to communicate with pts. families, and other providers

49
Q

Implementation process

A

-First thing nurses dois reassess pt
-Gather additonal info to ensure the plan of care is complete, current, and appropriate
-Confirm you’ve selected appropriate interventions
-Helps to decide whether the proposed nursing actions are still appropriate for a pt’s level of wellness
-After you reassess and if you need to add/modify the plan of care you need to review and revise the care plan
-Next you need to prepare for implementation by organizing time and resources
1. Equipment
2.Personal
3. Environment
4. Patient
-Lastly, anticipating and preventing complications

50
Q

Describe the Evaluation step in the nursing process

A

-The last step of the nursing process is evaluation
-Evaluation is an ongoing process
-Always evaluating when we enter a pt’s room
-Always documenting
-Going back and evaluating if what was done was effective
-Reassess to know if the intervention worked

51
Q

Describe the evualtion process

A

-Examine results
-Recognize errors or unmet outcomes
-Correct errors
-Revise the care plan
-Always document

52
Q

Genral critical thinking/Scientific method

A

-Systematic approach to gather data + solve problems
-Uses reasoning (5 steps of sceintific method)
-Gathering data and comparing data
Ex: vital signs data and comparing it to previous results

53
Q

What are the steps in the scientific method ?

A
  1. Identify the problem
  2. Collect data
  3. Formulate a question or hypothesis
  4. Test the question or hypothesis
  5. Evaluate results of the test or study

N125 Exam 1 Study guide (3 decks)

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