Nursing Process Flashcards
Nursing Process Steps
A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation
Assessment
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
Nursing Diagnosis
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
Planning
setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions
Implementation
performance of nursing interventions necessary for achieving goals/outcomes of nursing care
Evaluation
deciding whether, after interventions, a patient’s condition/well-being has improved
Relationship between Nursing Process & Critical Thinking
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
Health History
includes information about physical & developmental status, emotional health, resources, goals, values, lifestyle & expectations physical exam findings summary of lab results & diagnostic testing
Interview
organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information
Physical Exam
examining patient’s body to determine state of health
Observation
noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database
Subjective Data
patient’s verbal descriptions of problems
Objective Data
observations & measurements of patient’s health status
Sign
quality notices by others besides the patient
Symptom
quality reported by patient
Open-Ended Questions
questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation
Close-Ended Questions
questions that limits answer to 1-2 words
Back-Chanelling
giving positive comments during interview
Data Validation
comparison of data with another source to confirm accuracy *often leads to gathering more information
Components of Nursing Diagnosis
- 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)
Medical Diagnosis
identification of a disease condition based on an evaluation of physical signs, symptoms, history & diagnostic tests/ procedures *determined by physicians & advanced care nurses ONLY
Collaborative Problems
actual or potential physiological complication that nurses monitor to detect onset of changes in patient status
Cue
information obtained through use of senses
Inference
judgment of cues
Functional Health Patterns
theory/ practice standards that provide categories of information to assess
Focused Assessment
focus on patient situation beginning with problematic areas then asking follow-up questions
Data Cluster
set of signs & symptoms gathered during assessment grouped together logically
Data Analysis
recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response
NANDA-I
North American Nursing Diagnosis Association organization for nursing diagnoses
Defining Characteristics
clinical criteria or assessment finding that support an actual nursing diagnosis
Risk Diagnosis
diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient
Health Promotion Diagnosis
diagnosis that uses clinical judgment of patient’s motivation to increase well-being
Etiology
the cause of a problem, disease or condition (diagnosis) *always within domain of nursing practice *always a condition that responds to nursing interventions
PES Format
in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms
Expected Outcome
measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior
Nursing Sensitive Outcome
measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions
Nursing Outcomes Classification (NOC)
identifies, labels & validates nursing-sensitive outcomes
Independent Nursing Interventions
actions that nurses take that do not require order/direction
Dependent Nursing Interventions
actions that require order from a physician based on treating medical diagnosis
Evidence Based Practice
reviewing resources such as evidence in literature when choosing interventions
Nursing Interventions Classification (NIC)
set of nursing interventions that standardizes them
Nursing Care Plan
plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions
Interdisciplinary Care Plans
plans that include contributions from all disciplines involved in patient care
Critical Pathways
patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially
Consultation
seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation
Direct Care Interventions
treatments performed through interactions with patient
Indirect Care Interventions
treatments performed away from but on behalf of patient
Clinical Practice Guideline
“protocol” systematically developed set of statements that helps nurses & other providers make decision about appropriate health care
Instrumental Activities of Daily Living (IADLS)
skills such as shopping, preparing meals, writing checks & taking meds
Counseling
process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships
Standards of Nursing Care
helping independent professional that provides services that contribute to health of people care, cure & coordination
Activities that Occur in Planning
establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals
Guidelines for Writing Goals/Expected Outcomes
- 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
Components of Evaluation Process
identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions
Reversed
A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation
Nursing Process Steps
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
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
Reversed
setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions
Planning
Reversed
performance of nursing interventions necessary for achieving goals/outcomes of nursing care
Implementation
Reversed
deciding whether, after interventions, a patient’s condition/well-being has improved
Evaluation
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
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
Reversed
organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information
Interview
Reversed
examining patient’s body to determine state of health
Physical Exam
Reversed
noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database
Observation
Reversed
patient’s verbal descriptions of problems
Subjective Data
Reversed
observations & measurements of patient’s health status
Objective Data
Reversed
quality notices by others besides the patient
Sign
Reversed
quality reported by patient
Symptom
Reversed
questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation
Open-Ended Questions
Reversed
questions that limits answer to 1-2 words
Close-Ended Questions
Reversed
giving positive comments during interview
Back-Chanelling
Reversed
comparison of data with another source to confirm accuracy *often leads to gathering more information
Data Validation
Reversed
- 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
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
Reversed
actual or potential physiological complication that nurses monitor to detect onset of changes in patient status
Collaborative Problems
Reversed
information obtained through use of senses
Cue
Reversed
judgment of cues
Inference
Reversed
theory/ practice standards that provide categories of information to assess
Functional Health Patterns
Reversed
focus on patient situation beginning with problematic areas then asking follow-up questions
Focused Assessment
Reversed
set of signs & symptoms gathered during assessment grouped together logically
Data Cluster
Reversed
recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response
Data Analysis
Reversed
North American Nursing Diagnosis Association organization for nursing diagnoses
NANDA-I
Reversed
clinical criteria or assessment finding that support an actual nursing diagnosis
Defining Characteristics
Reversed
diagnosis that describes human responses to health conditions or life processes that may develop in a vulnerable patient
Risk Diagnosis
Reversed
diagnosis that uses clinical judgment of patient’s motivation to increase well-being
Health Promotion Diagnosis
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
Reversed
in nursing diagnosing, a three part label including problem, etiology, and signs/symptoms
PES Format
Reversed
measurable criteria to evaluate goal acheivement related to a change in patient physical condition or behavior
Expected Outcome
Reversed
measurable patient or family state, behavior or perception largely influenced by & sensitive to nursing interventions
Nursing Sensitive Outcome
Reversed
identifies, labels & validates nursing-sensitive outcomes
Nursing Outcomes Classification (NOC)
Reversed
actions that nurses take that do not require order/direction
Independent Nursing Interventions
Reversed
actions that require order from a physician based on treating medical diagnosis
Dependent Nursing Interventions
Reversed
reviewing resources such as evidence in literature when choosing interventions
Evidence Based Practice
Reversed
set of nursing interventions that standardizes them
Nursing Interventions Classification (NIC)
Reversed
plan that includes nursing diagnosis, goals/outcomes, specific nursing interventions
Nursing Care Plan
Reversed
plans that include contributions from all disciplines involved in patient care
Interdisciplinary Care Plans
Reversed
patient care management plans that provide interdisciplinary health team with activities & tasks to be put into practice sequentially
Critical Pathways
Reversed
seeking expertise of a specialist to identify ways to handle problems in patient care management or plan implementation
Consultation
Reversed
treatments performed through interactions with patient
Direct Care Interventions
Reversed
treatments performed away from but on behalf of patient
Indirect Care Interventions
Reversed
“protocol” systematically developed set of statements that helps nurses & other providers make decision about appropriate health care
Clinical Practice Guideline
Reversed
skills such as shopping, preparing meals, writing checks & taking meds
Instrumental Activities of Daily Living (IADLS)
Reversed
process that helps patient using problem-solving processes to recognize & manage stress & facilitate interpersonal relationships
Counseling
Reversed
helping independent professional that provides services that contribute to health of people care, cure & coordination
Standards of Nursing Care
Reversed
establish priorities setting goals and expected outcomes selection of interventions consulting other healthcare professionals
Activities that Occur in Planning
Reversed
- 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
Reversed
identifying criteria & standards collecting data interpreting & summarizing findings document findings care plan revisions
Components of Evaluation Process
