nursing process Flashcards

1
Q

organized and delivery of nursing care has to be

A

Dynamic

Continuous process

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2
Q

Use crintical thinking to:

A

make judgements and take actions based on reason

assists with responding to patient needs

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3
Q

as a nurse you need to be able to

A

identify

diagnose

treat human responses to health and wellness

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4
Q

nursing process promotes;

A

individualized nursing care

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5
Q

nursing process differentiates nursing practice

A

from other health care professionals

patients can be active participants

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6
Q

nursing process 5 components

A
assess
diagnose
plan
implement
evaluate
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7
Q

assess to

A

gather information about the clients condition

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8
Q

diagnose to

A

identify the clients problems

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9
Q

plan to

A

set goals of care and desired outcomes and identify appropriate nursing actions

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10
Q

implement to

A

perform the nursing actions identified in planning

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11
Q

evaluate to

A

determine if goals met and outcomes are achieved

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12
Q

critical thinking approach to assessment

A

involves collecting information from the patient and from secondary sources like family members, along with interpreting and validating the information to form a complete database

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13
Q

two stages of assessment

A

collection and verification of data

analysis of data

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14
Q

four components of assessment

A

knowledge

standards

attitudes

experience

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15
Q

knowledge of assessment

A

underlying disease process

normal growth and development

normal physiology and pychology

health promotion

assessment skills

communication skills

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16
Q

standards of assessment

A

ANA scope and standards of nursing process

specialty standards of practice

intellectual standards of measurement

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17
Q

attitude of assessment

A

perseverance

fairness

integrity

confidence

creativity

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18
Q

experience of assessment

A

pervious patient care experience

validation of assessment findings

observation of assessment techniques

19
Q

Types of assessments

A

patient-centered interview during a nursing health history

physical exam

periodic assessments made during rounding or administering care

20
Q

sources of data

A

patient

family and significant others

health care team

medical records

scientific literature

21
Q

patient data types

A

interview

observation

physical examination
(the best source of information)

22
Q

in order to obtain info from family you need to:

A

obtain patients agreement first

23
Q

types of data

A

subjective

objective

24
Q

subjective data

A

feelings,

perceptions,

self-report (verbal descriptions)

only patient can provide this information

25
objective data
observations or measurements ex size of rash, vital signs based on an accepted standard
26
data obtained through
physical exam, results of diagnostic and lab tests
27
patient centered interview
motivational interviewing effective communication interview preparation
28
phases of an interview
orientation and setting an agenda working phase termination
29
interview techniques
use open-ended questions use direct close-ended questions back channeling probing
30
open ended questions
describe situation in more than 1 or 2 words strengthens relationships because you're showing interest
31
back channeling ex
uh huh... go on
32
probing ex
what else?
33
cultural considerations
to conduct an accurate and complete assessment, you to to consider a patients cultural background when cultural differences exist between you and a patient, respect the unfamiliar and be sensitive to a patients uniqueness if you are unsure about what a patient is saying, ask for clarification to prevent making the wrong diagnostic conclusion
34
components of health history
biographical information reason for seeking health care health history psychosocial history patient expectations present illness or health concern family history spiritual health review of systems
35
observing patients level of function includes
the physical developmental psychological social aspects of everyday living
36
diagnostic and lab data
results provide further explanation of alterations or problems identified during the health history and physical examination or problems identified during the health history and physical exam
37
interpreting and validating assessment date to
ensure collection of complete database leads to second step of nursing process
38
interpreting assessment data and making nursing judgement
data validation analysis and interpretation
39
data validation to
ensure accuracy | this is what i have noticed
40
analysis and interpretation
data clustering
41
data clustering
signs and symptoms that are grouped together systems approach or functional health pattern approach to correctly classify and organize data focuses on identification of the correct problem certain cues
42
data documentation
use clear, concise appropriate terminology becomes baseline for care
43
concept mapping
visual representation that allows you to graphically show the connections among a patients many health problems