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Nursing Concepts > Nursing Process > Flashcards

Nursing Process Flashcards

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1
Q

Nursing Process Steps

A

A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation

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2
Q

Assessment

A

deliberate & systematic collection of data about a patient 1. collection/verification of data 2. analysis of data purpose=to establish a database of patient information

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3
Q

Nursing Diagnosis

A

clinical judgment about an individual, family or community responses to actual & potential health problems or life processes that the nurse is licensed & competent to treat *provides basis for selection of interventions

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4
Q

Planning

A

setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions

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5
Q

Implementation

A

performance of nursing interventions necessary for achieving goals/outcomes of nursing care

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6
Q

Evaluation

A

deciding whether, after interventions, a patient’s condition/well-being has improved

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7
Q

Relationship between Nursing Process & Critical Thinking

A

use of the Nursing Process is required to make nursing care decisions through critical thinking critical thinking required to analyze thoughts, actions & knowledge in nursing process

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8
Q

Health History

A

includes information about physical & developmental status, emotional health, resources, goals, values, lifestyle & expectations physical exam findings summary of lab results & diagnostic testing

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9
Q

Interview

A

organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information

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10
Q

Physical Exam

A

examining patient’s body to determine state of health

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11
Q

Observation

A

noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database

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12
Q

Subjective Data

A

patient’s verbal descriptions of problems

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13
Q

Objective Data

A

observations & measurements of patient’s health status

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14
Q

Sign

A

quality notices by others besides the patient

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15
Q

Symptom

A

quality reported by patient

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16
Q

Open-Ended Questions

A

questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation

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17
Q

Close-Ended Questions

A

questions that limits answer to 1-2 words

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18
Q

Back-Chanelling

A

giving positive comments during interview

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19
Q

Data Validation

A

comparison of data with another source to confirm accuracy *often leads to gathering more information

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20
Q

Components of Nursing Diagnosis

A
  1. diagnostic label- NANDA approved diagnosis name (EX: fatigue) 2. related factor- reason patient is displaying diagnosis (EX: related to depression) 3. defining characteristic (EX: evidenced by lack of energy)
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21
Q

Medical Diagnosis

A

identification of a disease condition based on an evaluation of physical signs, symptoms, history & diagnostic tests/ procedures *determined by physicians & advanced care nurses ONLY

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22
Q

Collaborative Problems

A

actual or potential physiological complication that nurses monitor to detect onset of changes in patient status

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23
Q

Cue

A

information obtained through use of senses

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24
Q

Inference

A

judgment of cues

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25
Q

Functional Health Patterns

A

theory/ practice standards that provide categories of information to assess

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26
Q

Focused Assessment

A

focus on patient situation beginning with problematic areas then asking follow-up questions

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27
Q

Data Cluster

A

set of signs & symptoms gathered during assessment grouped together logically

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28
Q

Data Analysis

A

recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response

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29
Q

NANDA-I

A

North American Nursing Diagnosis Association organization for nursing diagnoses

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30
Q

Defining Characteristics

A

clinical criteria or assessment finding that support an actual nursing diagnosis

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31
Q

Risk Diagnosis

A

diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient

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32
Q

Health Promotion Diagnosis

A

diagnosis that uses clinical judgment of patient’s motivation to increase well-being

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33
Q

Etiology

A

the cause of a problem, disease or condition (diagnosis) *always within domain of nursing practice *always a condition that responds to nursing interventions

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34
Q

PES Format

A

in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms

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35
Q

Expected Outcome

A

measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior

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36
Q

Nursing Sensitive Outcome

A

measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions

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37
Q

Nursing Outcomes Classification (NOC)

A

identifies, labels & validates nursing-sensitive outcomes

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38
Q

Independent Nursing Interventions

A

actions that nurses take that do not require order/direction

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39
Q

Dependent Nursing Interventions

A

actions that require order from a physician based on treating medical diagnosis

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40
Q

Evidence Based Practice

A

reviewing resources such as evidence in literature when choosing interventions

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41
Q

Nursing Interventions Classification (NIC)

A

set of nursing interventions that standardizes them

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42
Q

Nursing Care Plan

A

plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions

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43
Q

Interdisciplinary Care Plans

A

plans that include contributions from all disciplines involved in patient care

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44
Q

Critical Pathways

A

patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially

45
Q

Consultation

A

seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation

46
Q

Direct Care Interventions

A

treatments performed through interactions with patient

47
Q

Indirect Care Interventions

A

treatments performed away from but on behalf of patient

48
Q

Clinical Practice Guideline

A

“protocol” systematically developed set of statements that helps nurses & other providers make decision about appropriate health care

49
Q

Instrumental Activities of Daily Living (IADLS)

A

skills such as shopping, preparing meals, writing checks & taking meds

50
Q

Counseling

A

process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships

51
Q

Standards of Nursing Care

A

helping independent professional that provides services that contribute to health of people care, cure & coordination

52
Q

Activities that Occur in Planning

A

establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals

53
Q

Guidelines for Writing Goals/Expected Outcomes

A
  1. must be patient-centered 2. must be a singular goal/outcome 3. must be observable 4. must be measurable 5. must be time limited 6. must have mutual factors 7. must be realistic
54
Q

Components of Evaluation Process

A

identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions

55
Q

Reversed

A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation

A

Nursing Process Steps

56
Q

Reversed

deliberate & systematic collection of data about a patient 1. collection/verification of data 2. analysis of data purpose=to establish a database of patient information

A

Assessment

57
Q

Reversed

clinical judgment about an individual, family or community responses to actual & potential health problems or life processes that the nurse is licensed & competent to treat *provides basis for selection of interventions

A

Nursing Diagnosis

58
Q

Reversed

setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions

A

Planning

59
Q

Reversed

performance of nursing interventions necessary for achieving goals/outcomes of nursing care

A

Implementation

60
Q

Reversed

deciding whether, after interventions, a patient’s condition/well-being has improved

A

Evaluation

61
Q

Reversed

use of the Nursing Process is required to make nursing care decisions through critical thinking critical thinking required to analyze thoughts, actions & knowledge in nursing process

A

Relationship between Nursing Process & Critical Thinking

62
Q

Reversed

includes information about physical & developmental status, emotional health, resources, goals, values, lifestyle & expectations physical exam findings summary of lab results & diagnostic testing

A

Health History

63
Q

Reversed

organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information

A

Interview

64
Q

Reversed

examining patient’s body to determine state of health

A

Physical Exam

65
Q

Reversed

noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database

A

Observation

66
Q

Reversed

patient’s verbal descriptions of problems

A

Subjective Data

67
Q

Reversed

observations & measurements of patient’s health status

A

Objective Data

68
Q

Reversed

quality notices by others besides the patient

A

Sign

69
Q

Reversed

quality reported by patient

A

Symptom

70
Q

Reversed

questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation

A

Open-Ended Questions

71
Q

Reversed

questions that limits answer to 1-2 words

A

Close-Ended Questions

72
Q

Reversed

giving positive comments during interview

A

Back-Chanelling

73
Q

Reversed

comparison of data with another source to confirm accuracy *often leads to gathering more information

A

Data Validation

74
Q

Reversed

  1. diagnostic label- NANDA approved diagnosis name (EX: fatigue) 2. related factor- reason patient is displaying diagnosis (EX: related to depression) 3. defining characteristic (EX: evidenced by lack of energy)
A

Components of Nursing Diagnosis

75
Q

Reversed

identification of a disease condition based on an evaluation of physical signs, symptoms, history & diagnostic tests/ procedures *determined by physicians & advanced care nurses ONLY

A

Medical Diagnosis

76
Q

Reversed

actual or potential physiological complication that nurses monitor to detect onset of changes in patient status

A

Collaborative Problems

77
Q

Reversed

information obtained through use of senses

A

Cue

78
Q

Reversed

judgment of cues

A

Inference

79
Q

Reversed

theory/ practice standards that provide categories of information to assess

A

Functional Health Patterns

80
Q

Reversed

focus on patient situation beginning with problematic areas then asking follow-up questions

A

Focused Assessment

81
Q

Reversed

set of signs & symptoms gathered during assessment grouped together logically

A

Data Cluster

82
Q

Reversed

recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response

A

Data Analysis

83
Q

Reversed

North American Nursing Diagnosis Association organization for nursing diagnoses

A

NANDA-I

84
Q

Reversed

clinical criteria or assessment finding that support an actual nursing diagnosis

A

Defining Characteristics

85
Q

Reversed

diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient

A

Risk Diagnosis

86
Q

Reversed

diagnosis that uses clinical judgment of patient’s motivation to increase well-being

A

Health Promotion Diagnosis

87
Q

Reversed

the cause of a problem, disease or condition (diagnosis) *always within domain of nursing practice *always a condition that responds to nursing interventions

A

Etiology

88
Q

Reversed

in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms

A

PES Format

89
Q

Reversed

measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior

A

Expected Outcome

90
Q

Reversed

measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions

A

Nursing Sensitive Outcome

91
Q

Reversed

identifies, labels & validates nursing-sensitive outcomes

A

Nursing Outcomes Classification (NOC)

92
Q

Reversed

actions that nurses take that do not require order/direction

A

Independent Nursing Interventions

93
Q

Reversed

actions that require order from a physician based on treating medical diagnosis

A

Dependent Nursing Interventions

94
Q

Reversed

reviewing resources such as evidence in literature when choosing interventions

A

Evidence Based Practice

95
Q

Reversed

set of nursing interventions that standardizes them

A

Nursing Interventions Classification (NIC)

96
Q

Reversed

plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions

A

Nursing Care Plan

97
Q

Reversed

plans that include contributions from all disciplines involved in patient care

A

Interdisciplinary Care Plans

98
Q

Reversed

patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially

A

Critical Pathways

99
Q

Reversed

seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation

A

Consultation

100
Q

Reversed

treatments performed through interactions with patient

A

Direct Care Interventions

101
Q

Reversed

treatments performed away from but on behalf of patient

A

Indirect Care Interventions

102
Q

Reversed

“protocol” systematically developed set of statements that helps nurses & other providers make decision about appropriate health care

A

Clinical Practice Guideline

103
Q

Reversed

skills such as shopping, preparing meals, writing checks & taking meds

A

Instrumental Activities of Daily Living (IADLS)

104
Q

Reversed

process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships

A

Counseling

105
Q

Reversed

helping independent professional that provides services that contribute to health of people care, cure & coordination

A

Standards of Nursing Care

106
Q

Reversed

establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals

A

Activities that Occur in Planning

107
Q

Reversed

  1. must be patient-centered 2. must be a singular goal/outcome 3. must be observable 4. must be measurable 5. must be time limited 6. must have mutual factors 7. must be realistic
A

Guidelines for Writing Goals/Expected Outcomes

108
Q

Reversed

identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions

A

Components of Evaluation Process

Nursing Concepts (16 decks)

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