Nursing Process Flashcards
1
Q
Nursing Process Steps
A
A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation
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
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
4
Q
Planning
A
setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions
5
Q
Implementation
A
performance of nursing interventions necessary for achieving goals/outcomes of nursing care
6
Q
Evaluation
A
deciding whether, after interventions, a patient’s condition/well-being has improved
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
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
9
Q
Interview
A
organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information
10
Q
Physical Exam
A
examining patient’s body to determine state of health
11
Q
Observation
A
noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database
12
Q
Subjective Data
A
patient’s verbal descriptions of problems
13
Q
Objective Data
A
observations & measurements of patient’s health status
14
Q
Sign
A
quality notices by others besides the patient
15
Q
Symptom
A
quality reported by patient
16
Q
Open-Ended Questions
A
questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation
17
Q
Close-Ended Questions
A
questions that limits answer to 1-2 words
18
Q
Back-Chanelling
A
giving positive comments during interview
19
Q
Data Validation
A
comparison of data with another source to confirm accuracy *often leads to gathering more information
20
Q
Components of Nursing Diagnosis
A
- 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)
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
22
Q
Collaborative Problems
A
actual or potential physiological complication that nurses monitor to detect onset of changes in patient status
23
Q
Cue
A
information obtained through use of senses
24
Q
Inference
A
judgment of cues
25
Functional Health Patterns
theory/ practice standards that provide categories of information to assess
26
Focused Assessment
focus on patient situation beginning with problematic areas then asking follow-up questions
27
Data Cluster
set of signs & symptoms gathered during assessment grouped together logically
28
Data Analysis
recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response
29
NANDA-I
North American Nursing Diagnosis Association organization for nursing diagnoses
30
Defining Characteristics
clinical criteria or assessment finding that support an actual nursing diagnosis
31
Risk Diagnosis
diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient
32
Health Promotion Diagnosis
diagnosis that uses clinical judgment of patient's motivation to increase well-being
33
Etiology
the cause of a problem, disease or condition (diagnosis) \*always within domain of nursing practice \*always a condition that responds to nursing interventions
34
PES Format
in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms
35
Expected Outcome
measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior
36
Nursing Sensitive Outcome
measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions
37
Nursing Outcomes Classification (NOC)
identifies, labels & validates nursing-sensitive outcomes
38
Independent Nursing Interventions
actions that nurses take that do not require order/direction
39
Dependent Nursing Interventions
actions that require order from a physician based on treating medical diagnosis
40
Evidence Based Practice
reviewing resources such as evidence in literature when choosing interventions
41
Nursing Interventions Classification (NIC)
set of nursing interventions that standardizes them
42
Nursing Care Plan
plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions
43
Interdisciplinary Care Plans
plans that include contributions from all disciplines involved in patient care
44
Critical Pathways
patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially
45
Consultation
seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation
46
Direct Care Interventions
treatments performed through interactions with patient
47
Indirect Care Interventions
treatments performed away from but on behalf of patient
48
Clinical Practice Guideline
"protocol" systematically developed set of statements that helps nurses & other providers make decision about appropriate health care
49
Instrumental Activities of Daily Living (IADLS)
skills such as shopping, preparing meals, writing checks & taking meds
50
Counseling
process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships
51
Standards of Nursing Care
helping independent professional that provides services that contribute to health of people care, cure & coordination
52
Activities that Occur in Planning
establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals
53
Guidelines for Writing Goals/Expected Outcomes
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
Components of Evaluation Process
identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions
55
# Reversed
A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation
Nursing Process Steps
56
# 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
Assessment
57
# 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
Nursing Diagnosis
58
# Reversed
setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions
Planning
59
# Reversed
performance of nursing interventions necessary for achieving goals/outcomes of nursing care
Implementation
60
# Reversed
deciding whether, after interventions, a patient's condition/well-being has improved
Evaluation
61
# 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
Relationship between Nursing Process & Critical Thinking
62
# Reversed
includes information about physical & developmental status, emotional health, resources, goals, values, lifestyle & expectations physical exam findings summary of lab results & diagnostic testing
Health History
63
# Reversed
organized conversation with patient orientation phase, working phase, termination phase \*patient is the best source of information
Interview
64
# Reversed
examining patient's body to determine state of health
Physical Exam
65
# Reversed
noticing patient behavior (verbal & nonverbal), patient function \*adds depth to objective database
Observation
66
# Reversed
patient's verbal descriptions of problems
Subjective Data
67
# Reversed
observations & measurements of patient's health status
Objective Data
68
# Reversed
quality notices by others besides the patient
Sign
69
# Reversed
quality reported by patient
Symptom
70
# Reversed
questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation
Open-Ended Questions
71
# Reversed
questions that limits answer to 1-2 words
Close-Ended Questions
72
# Reversed
giving positive comments during interview
Back-Chanelling
73
# Reversed
comparison of data with another source to confirm accuracy \*often leads to gathering more information
Data Validation
74
# 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)
Components of Nursing Diagnosis
75
# 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
Medical Diagnosis
76
# Reversed
actual or potential physiological complication that nurses monitor to detect onset of changes in patient status
Collaborative Problems
77
# Reversed
information obtained through use of senses
Cue
78
# Reversed
judgment of cues
Inference
79
# Reversed
theory/ practice standards that provide categories of information to assess
Functional Health Patterns
80
# Reversed
focus on patient situation beginning with problematic areas then asking follow-up questions
Focused Assessment
81
# Reversed
set of signs & symptoms gathered during assessment grouped together logically
Data Cluster
82
# Reversed
recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response
Data Analysis
83
# Reversed
North American Nursing Diagnosis Association organization for nursing diagnoses
NANDA-I
84
# Reversed
clinical criteria or assessment finding that support an actual nursing diagnosis
Defining Characteristics
85
# Reversed
diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient
Risk Diagnosis
86
# Reversed
diagnosis that uses clinical judgment of patient's motivation to increase well-being
Health Promotion Diagnosis
87
# Reversed
the cause of a problem, disease or condition (diagnosis) \*always within domain of nursing practice \*always a condition that responds to nursing interventions
Etiology
88
# Reversed
in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms
PES Format
89
# Reversed
measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior
Expected Outcome
90
# Reversed
measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions
Nursing Sensitive Outcome
91
# Reversed
identifies, labels & validates nursing-sensitive outcomes
Nursing Outcomes Classification (NOC)
92
# Reversed
actions that nurses take that do not require order/direction
Independent Nursing Interventions
93
# Reversed
actions that require order from a physician based on treating medical diagnosis
Dependent Nursing Interventions
94
# Reversed
reviewing resources such as evidence in literature when choosing interventions
Evidence Based Practice
95
# Reversed
set of nursing interventions that standardizes them
Nursing Interventions Classification (NIC)
96
# Reversed
plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions
Nursing Care Plan
97
# Reversed
plans that include contributions from all disciplines involved in patient care
Interdisciplinary Care Plans
98
# Reversed
patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially
Critical Pathways
99
# Reversed
seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation
Consultation
100
# Reversed
treatments performed through interactions with patient
Direct Care Interventions
101
# Reversed
treatments performed away from but on behalf of patient
Indirect Care Interventions
102
# Reversed
"protocol" systematically developed set of statements that helps nurses & other providers make decision about appropriate health care
Clinical Practice Guideline
103
# Reversed
skills such as shopping, preparing meals, writing checks & taking meds
Instrumental Activities of Daily Living (IADLS)
104
# Reversed
process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships
Counseling
105
# Reversed
helping independent professional that provides services that contribute to health of people care, cure & coordination
Standards of Nursing Care
106
# Reversed
establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals
Activities that Occur in Planning
107
# 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
Guidelines for Writing Goals/Expected Outcomes
108
# Reversed
identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions
Components of Evaluation Process
