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Nursing Process & Critical Thinking Flashcards

1
Q

what are the FIVE STEPS OF THE NURSING PROCESS?

A

**ADPIE

  1. ASSESSMENT
  2. DIAGNOSIS
  3. PLAN
  4. IMPLEMENT
  5. EVALUATE
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2
Q

definition of ASSESSMENT

A

gathering INFORMATION about the patient’s condition

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3
Q

what do we need to FACTOR IN DURING ASSESSMENT?

A
  • use of CRITICAL THINKING SKILLS
  • want to GATHER AS MUCH INFORMATION AS POSSIBLE
  • have to COLLECT, REVIEW, & ANALYZE the DATA
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4
Q

what are the TWO STAGES OF ASSESSMENT?

A
  1. want to first COLLECT information either from a PRIMARY SOURCE (the patient themselves) or SECONDARY SOURCES (the family, charting)
  2. want to then INTERPRET & VALIDATE THE DATA
    is this data needed?
    does the data make sense?
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5
Q

what are our TYPES OF ASSESSMENTS?

A
  • PATIENT CENTERED INTERVIEW
  • PERIODIC ASSESSMENTS
  • PHYSICAL EXAMINATION
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6
Q

definition of patient-centered interview

A

conducted during nursing history

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7
Q

definition of PERIODIC ASSESSMENTS

A

conducted during ONGOING CONTACT WITH PATIENTS
- going throughout the shift

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8
Q

definition of PHYSICAL EXAMINATION

A

conducted during the NURSING HISTORY or any time the patient presents a SYMPTOM

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9
Q

what are OUR TYPES OF DATA?

A
  • SUBJECTIVE
  • OBJECTIVE
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10
Q

definition of SUBJECTIVE DATA

A

the patient’s own VERBAL DESCRIPTIONS of their health issues
specific feelings or perceptions

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11
Q

definition of OBJECTIVE DATA

A

findings that come from DIRECT OBSERVATION

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12
Q

what are some important parts of a NURSING HEALTH HISTORY?

A
  • PMH
  • FAMILY HISTORY
  • PERSONAL & SOCIAL HISTORY
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13
Q

definition of CULTURAL COMPETENCE

A

having the SELF AWARENESS AND PRACTICE and knowledge of a patient’s core cultural background

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14
Q

definition of CULTURAL HUMILITY

A

ability to RECOGNIZE UR OWN KNOWLEDGE LIMITATIONS and perspectives
still being open

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15
Q

how should data documentation be like?

A

should be CLEAR AND CONCISE and using PROPER TERMINOLOGY
- be able to RECORD AND EVALUATE INTERVENTIONS

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16
Q

definition of DATA COLLECTION

A

use of INFORMATION about a patient’s needs to adapt your data collection

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17
Q

definition of INTERPRETATION

A

ability to INTERPRET ASSESSMENT DATA TO see if there are ABNORMALITIES

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18
Q

definition of VALIDATION

A

comparing data with other sources to determine ACCURACY

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19
Q

what is CONCEPT MAPPING?

A

being able to ORGANIZE YOUR ASSESSMENT DATA
- being able to PLACE ALL THE CUES TOGETHER and look for PATTERNS

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20
Q

definition of DIAGNOSIS

A

have the IDENTIFICATION OF A HEALTH-RELATED PROBLEM or the POTENTIAL OF A PROBLEM TO DEVELOP based upon patient data

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21
Q

what are the TYPES OF DIAGNOSIS?

A
  • MEDICAL DIAGNOSIS
  • NURSING DIAGNOSIS
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22
Q

what is the DIFFERENCE BETWEEN MEDICAL & NURSING DIAGNOSES?

A
  • medical diagnoses are MORE SPECIFIC to the disease a patient has
  • NURSING DIAGNOSES are specific to the CLINICAL JUDGEMENT of the patient

ex. med. diagnosis - COPD
ex. nursing diag. - ineffective breathing pattern

23
Q

how do we WRITE OUT NURSING DIAGNOSES?

A

through the PES FORMAT

24
Q

describe the PES FORMAT

A
  1. PROBLEM
  2. ETIOLOGY
  3. SYMPTOMS
    - associated data
    - subjective data
    - objective data

(1)problem r/t (2)etiology a.e.b/a.m.b. (3) symptoms

25
definition of COLLOBORATIVE PROBLEMS
problem that REQUIRES BOTH MEDICINE AND NURSING INTERVENTIONS totreat
26
what is considered a NURSING DIAGNOSIS?
if the nurse can PREVENT THE COMPLICATION or PROVIDE THE PRIMARY TREATMENT for it
27
definition of PROBLEM FOCUSED DIAGNOSIS
identifying an UNDESIRABLE HUMAN RESPONSE to existing problems or concerns of the patient
28
definition of a RISK DIAGNOSIS
diagnoses that apply when there is an INCREASED POTENTIAL or VULNERABILITY for a patient to develop a PROBLEM OR COMPLICATION
29
definition of a HEALTH PROMOTION DIAGNOSIS
identifying the DESIRE OR MOTIVATION to improve health status through a positive behavioral change
30
definition of DATA CLUSTERING
set of assessment findings and defining specific characteristics - being able to be MORE SPECIFIC AND COMPARE DATA -- focused in specific PATTERSN
31
definition of DATA INTERPRETATION
putting specific LABELS ON PATTERNS and IDENTIFYING PATIENT RESPONSES
32
where do DIAGNOSTIC ERRORS OCCUR?
- improper DATA COLLECTION - CLUSTERING - wrong ANALYSIS OR INTERPRETATION OF DATA - improper diagnostic statement
33
why are DIAGNOSES SO IMPORTANT?
allow for a PROPER SELECTION OF NURSING INTERVENTIONS to achieve DESIRED OUTCOMES for patients - sets an important start for a ROAD MAP OF DELIVERING CARE
34
what is within the PROCESS OF PLANNING NURSING CARE?
- being able to SET PRIORITIES - being able to IDENTIFY PATIENT-CENTERED GOALS - having the proper PRESCRIPTION OF NURSING INTERVENTIONS
35
what is the IMPORTANCE SCALE FOR NURSING DIAGNOSES?
HIGH: - very important if left untreated can cause HARM TO PATIENT - maslow INTERMEDIATE: - nonemergent or non-lifethreatening LOW: - not typically directly related to illness specifically--but can affect the patient's future well-being
36
what about GOALS, how do they play out during PLANNING?
important to consider because this is the end finish line that we want to achieve! - is this goal SHORT-TERM or LONG-TERM? important to be REALISTIC with the goal and priorities that you set
37
definition of SMART GOALS
SMART - in setting your goals! S - be SPECIFIC M - it should be MEASURABLE A - it should be ATTAINABLE (whether that is during your shift or throughout recovery) R - be REALISTIC T - should be TIME FOCUSED
38
what are the TYPES OF INTERVENTIONS?
- NURSE INITIATED - HEALTH CARE PROVIDER INITIATED - OTHER PROVIDER INITIATED
39
what is the NURSING INTERVENITONS CLASSIFICATION
type of model that is divided into DOMAINS, CLASSES, & INTERVENTIONS - helps to ENHANCE COMMS between nurses and setting standards for nursing interventions
40
definition of DIRECT CARE INTERVENTIONS
treatments that nurses PROVIDE through interactions with the patient or group of patients
41
definition of INDIRECT CARE INTERVENTIONS
treatments that are PERFORMED AWAY from a patient but on the BEHALF OF THE PATIENT or group of patients - documentation/usage of consultation etc...
42
definition of STANDARD INTERVENTIONS
- interventions that allow the nurses to ACT QUICKLY & APPROPRIATELY - captures patient care information that can be shared across disciplines or care settings
43
what are some interventions?
- care bundles - PRN orders/standing orders - standards of practice
44
definition of CLINICAL PRACTICE GUIDELINES AND PROTOCOLS
systemically developed set of statements that are appropriate health care for specific health care problems
45
definition of a CARE BUNDLE
group of interventions that are RELATED TO A DISEASE PROCESS OR CONDITION
46
definition of STANDING ORDERS
- prepreinted document that contains MEDICAL ORDERS - directs patient care in a specific clinical setting
47
what are STANDARDS OF PRACTICE?
use of ANA STANDARDS OF PROFESSIONAL NURSING PRACTICE
48
definition of QSEN
- the QUALITY AND SAFETY EDUCATION FOR NURSES - gives proper KNOWLEDGE, SKILLS, and attitudes for the prep of future nurses
49
what to consider BEFORE IMPLEMENTATION?
- what are all POSSIBLE INTERVENTIONS for this patient? - are there any CONSEQUENCES for this action?
50
how can we PREVENT COMPLICATIONS?
- identifying RISKS to the patient - adapting interventions to the situation - comparing the BENEFIT AND RISK
51
definiton of EVALUATION
determining if a PATIENTS CONDITION is being IMPROVED AFTER THE NURSING INTERVENTIONS THAT WERE IMPLEMENTED
52
how do we EVALUATE?
want to look at the OUTCOMES AND DO A BEFORE AND AFTER COMPARISON OF STANDARDS - examine results from patient, family, and other nurses - do these results match with the goals set for this patient?
53
what happens if the OUTCOMES DONT MATCH GOALS?
- either can DISCONTINUE OR MODIFY THE CARE PLAN - have to REDEFINE OUR DIAGNOSES - REVISE GOALS AND EXPECTED OUTCOMES - REVISE INTERVENTIONS

NURS 200 (24 decks)

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