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Test II N121 > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

Purpose of Nursing Process

A
  1. ID health status, actual/potential problems and needs
  2. Establish plans to meet IDed needs
  3. deliver interventions to meed needs
  4. Evaluate success
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2
Q

Assessment Definition

A

Systematic and continuous collection of data about client focused on client responses to health problem

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3
Q

Types of Assessment

A

Initial, Problem-focused, Emergency, and Time-lapsed

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4
Q

4 Assessment Processes

A
  1. Collecting Data, 2. Organizing Data, 3. Validating data, 4. Documenting Data
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5
Q

subjective data

A

symptoms apparent only to the client, described or varified by client. Client’s sensations, feelings, values, beliefs, attitudes, and perceptions

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6
Q

Objective Data

A

Signs- detectable to observer, measured/tested against standards, can be seen, heard, felt, or smelled

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7
Q

Sources of Data

A

Client (primary/subjective), support people, client records, HCP, Literature

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8
Q

Data Collection Methods

A

Observing, Interviewing, and Examing

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9
Q

Observing

A

Gathering data via senses. conscious and deliberate

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10
Q

Interviewing

A

planned communication/conversation with client. Directive or Nondirective

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11
Q

Examining

A

physical assessment via inspection, auscultation, palpation, and percussion

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12
Q

Organizing Data

A

Use written or digital format to organize assessment data systematically

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13
Q

Validating Data

A

double checking data for consistency and that its complete, factual, and accurate to allow diagnosis and intervention to be based on info

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14
Q

Cues

A

subjective/objective data that can be directly observed by nurse

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15
Q

Inferences

A

Nurse’s interpretation/conclusion made based on cues

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16
Q

Diagnosis Definition

A

statement made by nurse about client’s health problem including: diagnostic label (P), causal relationship (E), and defining characteristics (S/S)

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17
Q

5 Types of Nursing Diagnosis

A

Actual, Risk, Wellness, Health Promotion, and Syndrome

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18
Q

Actual Diagnosis

A

client problem present at time of nursing assessment and is based on presence of S/S

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19
Q

Risk nursing Diagnosis

A

Presence of risk factors indicates that problem is likely to develop e/o interventions

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20
Q

Wellness Diagnosis

A

human response to levels of wellness in client that have a readiness for enhancement

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21
Q

Health Promotion

A

Client’s motivation and desire to increase well-being and actualize health potential

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22
Q

Syndrom diagnosis

A

associated with cluster of other diagnosis

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23
Q

Diagnosis- Problem

A

client’s health problem or response for nursing care to be given. Few words, specific, guiding

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24
Q

Diagnosis- Etiology

A

related factors and risk factors. Probable causes of health problem. Individualizes client care

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25
Q

Diagnosis- Defining Characteristics

A

signs and symptoms that indicate presence of particular diagnostic label. Signs and symptoms of PROBLEM

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26
Q

Steps of Diagnostic Process

A

Analyzing Data, ID health problems/risks, formulating diagnostic statement

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27
Q

Analyzing Data

A

Diagnostic Process- comparing data against standards, clustering cues, and Final checks for inconsistencies

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28
Q

Significant Cues

A

points to negative/positive change in health status or pattern.

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29
Q

Clustering Cues

A

determine relatedness of facts and patterns

30
Q

Plan

A

Deliberate, systematic phase where nurse forms client’s plan of care and refers to assessment and diagnosis to formulate goals and design interventions

31
Q

Nursing Interventions

A

treatment nurse performs to enhance patient outcomes and achieve goals

32
Q

Types of Planning

A

Initial, ongoing, discharge

33
Q

Intial planning

A

initial plan of care developed at admission assessment

34
Q

Ongoing Planning

A

Done by all nurses who work w/ client to be updated and evaluate client’s response to care. Done at begining of shift

35
Q

Discharge Planning

A

anticipating and planning needs after discharge, essential to comprehensive care. Begins at first contact and ongoing

36
Q

Types of Care Plans

A

Informal, Formal, Standardized, and Individualized

37
Q

Informal Nursing Care plan

A

plan that exists in nurse’s mind

38
Q

Formal Nursing Care Plan

A

written/computerized guide that organizes info.

39
Q

Standardized Care Plan

A

formal plan that specifies nursing care for groups of clients with common needs

40
Q

Individualized Care Plan

A

tailored to meet unique needs of specific client

41
Q

Care Plans

A

actions nurses must take to address client’s nursing diagnoses, produce desired outcomes, integrate independent/dependent nursing fuctions

42
Q

Care Plans- Nurse needs to..

A

ID what problems need to be individualized or standardized, individualize desired outcomes

43
Q

Documents in Plan of Care

A

describe routine care needed to meet basic needs, client’s nursing diagnosis, specify nursing responsibilities in carrying out medical diagnosis

44
Q

Planning Process

A

Setting priorities, est. client goals, selecting nursing interventions, writing individualized nursing interventions on care plans

45
Q

Setting Priorities

A

Planning- preferential sequence of action. Based on client’s responses, problems, and therapies

46
Q

Establishing Client Goals

A

Planning- broad statements that are: observable/measurable responses, realistic, time-specific, and client centered

47
Q

Long-term Goals

A

guide planning for discharge to long-term agencies/home care. weeks to months

48
Q

Short-term Goals

A

short-time health care. hours to days

49
Q

Goal Statements

A

Subject (client), Verb (action performed/directly observable behaviors), Conditions/modifiers (When, what, how), and Criterion of goal (time, speed, distance, etc.)

50
Q

Focus of Nursing Interventiosn

A

Achieve goal via eliminating/reducing etiology and treat S/S

51
Q

Types of Nursing Interventions

A

Independent, Dependent, Collaborative

52
Q

Delegation

A

transfer of responsibility for performing task while retaining responsibility of outcome

53
Q

Assignment

A

downward/lateral transfer of both task responsibility and accountablility

54
Q

Implementation Definition

A

nurse performs nursing interventions written from planning phase. Doing/documenting specific nursing actions need to carry out intervention

55
Q

Process of Implementation

A

reassessing client, determining nurse’s need for assistance, implementing nursing interventions, supervising delegated care, documenting

56
Q

Reassessing Patient

A

Implementation-intervention still needed? reset priorities?

57
Q

Need for assisstance

A

Implementation- does the nurse need help to perform activity safely and efficiently

58
Q

Implement nursing interventions

A

Implementation- Provide Patient teaching (what, purpose, sensations, participation, outcomes)

59
Q

Supervising Delegated Care

A

Implementation- responsible for client’s overall care and must ensure activities have been implemented correctly

60
Q

Document Nursing Activities

A

Implementation- completes implementation phase via recording interventions and client’s response

61
Q

Evaluation

A

planned, ongoing, purposeful activity to determine progress towards goal achievement and effectiveness of nursing plan of care

62
Q

Result of Evaluation

A

nursing interventions are terminated, continued, or changed

63
Q

Types of Evaluation

A

continuous, specific interval, and discharge

64
Q

Continuous Evaluation

A

during and immediately after implementation of nursing intervention- can be modified

65
Q

Specific Interval Evaluation

A

shows extent of progress toward goal

66
Q

Discharge evaluation

A

status of goal achievement and clients self-care abilities and follow up care

67
Q

Process of Evaluation

A

Collecting data related to desired outcomes, comparing data with outcomes, relating nursing activities to outcomes, drawing conclusions about problem status, and continuing/modifying/terminating nursing care plan

68
Q

Thress Conclusions of evaluation

A

Goal was met- client’s response= desired outcomes.
Goal was partially met- short-term goal achieved but long-term wasn’t. Or desired outcome only partially reached
Goal was not met

69
Q

Evaluation Statement

A

Conclusion (met, partially met, not met) and supporting data (client’s responses)

70
Q

Critical Thinking Definition

A

a discipline specific, reflective reasoning process that guides a nurse in generating implementing, and evaluating approaches for dealing with client care and professional concerns

Test II N121 (2 decks)

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