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fundamentals of nursing > Nursing Process: PIE > Flashcards

Nursing Process: PIE Flashcards

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1
Q

_____ process of designing an action plan through which lifestyle behaviors can be prevented, reduced or eliminated.

A

Planning

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2
Q

It involves decision making and problem solving.

A

Planning

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3
Q

What is the end product of the planning phase?

A

NURSING CARE PLAN

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4
Q

3 types of planning

A
  • initial planning
  • on going planning
  • discharge planning
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5
Q

A plan that develops a preliminary plan of care by the nurse during admission assessment

A

Initial planning

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6
Q

It is a continuous updating of client’s plan of care. Nurse can _____ the initial plan further

A
  • ongoing planning
  • individualize
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7
Q

Occurs at the beginning of a shift as the nurse plans the care to be given that day

A
  • ongoing planning
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8
Q

Using ongoing assessment data, the nurse carries out daily planning for the following purposes:

  • To determine whether the client’s _____ has______
  • To______ for the client’s care during the ________
  • To decide which ________ on during the shift
  • To________ the nurse’s activities so that more than one problem can be addressed at each client contact.
A
  • health status, changed
  • set priorities, shift
  • problems to focus
  • coordinate
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9
Q

A plan that involves critical anticipation and planning for clients needs after discharge

A
  • discharge planning
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10
Q

Tasks Involved with Planning

-__________ list of nursing diagnoses.
- Identifying and writing client-centered long- and short-term ______ and______.
- Developing specific_________
-__________ entire nursing plan in client’s record.

A
  • prioritizing
  • goals, outcomes
  • nursing interventions
  • recording
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11
Q

What theory is used in prioritizing the client’s setting or situation

A

Maslow’s hierarchy of needs

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12
Q

What is the sequence for addressing nursing diagnoses and interventions.

A
  • life- threatening problems
  • health- threatening problems
  • low priority
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13
Q

Which of these problems is a priority?

  • Ineffective Airway Clearance
  • Deficient fluid volume
  • Anxiety related to difficulty breathing
  • Risk for interrupted family processes
  • Impaired nutrition
  • Sleep pattern disturbance
A

(H)
(H)
(M)
(L)
(L)
(L)

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14
Q

Why should there be goals?

  • Provide______ for planning interventions.
  • Serve as________ for_______ client progress.
  • Enable the client and nurse to determine when the problem has been_______.
  • Help________ the client & nurse by providing a sense of________.
A
  • direction
  • criteria, evaluating
  • resolved
  • motivate, achievement
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15
Q

Two types of goal/ outcome

A
  • short term outcome
  • long term outcome
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16
Q

Short term outcome is used when a client is only admitted in the hospital for few _____. While long term outcome is used for patients that will stay over ______

A
  • Hours or days
  • weeks or months
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17
Q

Objective formulation must be _____

A

SMART
Specific
Measurable
Attainable
Realistic
Time-bounded

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18
Q

What are the essential components of objectives?

A
  • criterion
  • subject
  • task statement or verb- action
  • conditions or modifiers
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19
Q

What are the categories in Bloom’s taxonomy in writing an objective

A
  • Remember
  • understand
  • apply
  • analyze
  • evaluate
  • create
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20
Q

_____________ is an action performed by the nurse that helps the client achieve the results specified by the goals and expected outcomes.

A

nursing intervention

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21
Q

Nursing interventions are identified and written during ______ step of nursing process

A

Planning

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22
Q

Types of nursing intervention

A
  • independent
  • dependent
  • collaborative
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23
Q

Nursing intervention that nurses are licensed to initiate on the basis of their knowledge & skills.

Includes: Physical care, ongoing assessment, emotional support, comfort, teaching, counseling, environmental management

A

Independent

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24
Q

Nursing intervention that is carried out under the physician’s orders or supervision according to specified routines.

Includes: Providing medications, intravenous therapy, treatment, diet and activity, changing dressing, administering the medical orders, assess the need for explaining.

A

Dependent

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25
Q

Nursing intervention that nurse carries out in collaboration with other health team members.

A

Collaborative

26
Q

Identify whether the nursing actions are independent, dependent or collaborative

  • Review & convey abnormal laboratory results to physician
  • Assisting the client with oral care
  • Giving oral medication to client
  • Referring client to dietician
  • Assessing pain level
  • Positioning client during mealtime
  • Supporting patient emotionally
  • Dextrose /Putting V
  • Diagnostic Test
  • Diet and Activity
  • Wound Dressing
  • Environmental Management
A

C
I
D
C
I
I
D
D
D
D
I

27
Q

Criteria for Selecting Nursing Interventions

  • Safe & appropriate for client’s______,_______ &_______
  • Achievable with the_______ available.
  • Congruent with client’s_______,_______, and_______.
  • Congruent with other________
  • Based on nursing knowledge & experience or rationale
  • Within established standards of care by laws, & policies set by the institution, organization or country.
A
  • age, health, condition
  • resource
  • values, beliefs, culture
  • therapies
28
Q
  • “Action phase”
  • Reassessing the client
  • Determining the nurse’s need for assistance
  • Implementing the nursing interventions
  • Supervising the delegated care
  • Documenting nursing activities
A

IMPLEMENTATION PHASE

29
Q

• consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.

A

Implementing

30
Q

Skills involved in the implementation phase

A
  • cognitive skill
  • interpersonal skill
  • technical skill
31
Q

intellectual skills include problem solving, decision making, critical thinking, clinical reasoning, and creativity.

A

Cognitive skills

32
Q

all of the activities, verbal and non-verbal, people use wher interacting directly with one another.

  • The effectiveness of a nursing action often depends largely on the nurse’s ability to________ with others.
A

Interpersonal skills

communicate

33
Q

are purposeful “hands-on” skills such as manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients.

also called tasks, procedures, or psychomotor skills.

A

Technical skills

34
Q

Process of Implementing
1._______ the client
2. Determining the nurse’s_______ for assistance
3. Implementing the________
4.__________ delegated care
5.__________ nursing activities

A
  • reassessing
  • need
  • nursing intervention
  • supervising
  • documenting
35
Q

The evaluation phase has five components:

-_________ related to the desired outcomes
-__________ the data with desired outcomes
-__________ nursing activities to outcomes
- Drawing_________ about problem status
-_________,_________, or__________ the nursing care plan

A
  • collecting data
  • comparing
  • relating
  • conclusions
  • continuing, modifying, terminating
36
Q

end prodcut of planning phase is

A

nursing care plan

37
Q

stage of nursing process that use long term and short term goal

A

planning

38
Q

Does the the priorities change as tbe client responses, problesma nd therapies change?

A

yes

39
Q

is it assigned as a medium priority

A

health threatening problem

40
Q

what kind of problem

impaired respiratory /cardiac function

ineffective airway clearance
deficient fluid volume

A

life threatening prob

41
Q

may result in delay deveopment or cause destructive physical or emotional change

A

heatlh threatening prob

42
Q

arises from “normal deveopment needs”

requires MINIMAL nursing support

A

Low priority

43
Q

identify the priority

Ineffective Airway Clearance
Deficient fluid volume
Anxiety related to difficulty breathing
Risk for interrupted family processes
Impaired nutrition
Sleep pattern disturbance

A

HIGH- Ineffective Airway Clearance
HIGH- Deficient fluid volume
MEDIUM- Anxiety related to difficulty breathing
LOW- Risk for interrupted family processes
LOW- Impaired nutrition
LOW- Sleep pattern disturbance

44
Q

goals serve as a criteria for evaluating client progress

t or f

A

t

45
Q

goals help motivate client n nurse by providing a sense of achievement

t or f

A

t

46
Q

2 kinds of outcomes

A

short term and long term outcome (planning

47
Q

statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis in a short period of time, usually in a few hours or days. - as students in hospitals

A

short term

48
Q

statement written in objective format demonstrating an expectation to be achieved in resolution of the nursing diagnosis over a long period of time, usually over weeks or months.
Objective Formulation)

A

Long term

49
Q

easier to monitor progress and know when it is obtain or finished

(smart)

A

MEASURABLE

50
Q

goals should be flexible yet still remains possible

smart

A

attainable

51
Q

ESSENTIAL components of objectives cstc

A

criterion of desired performance
subject
task statement or verb action
conditions or modifiers

52
Q

explain the “circumstances” under which behavior is to be perfome

A

conditions/modifier

53
Q

availability of “resources”

A

REALISTIC

54
Q

consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.

A

implementation

55
Q

takes place at the end of the learning process to ascertain if the objectives have been achieved and competencies developed

A

summative evaluation

56
Q

strives to assess the effectiveness of the nursing actions performed

focuses more on the desired outcome

A

summative evaluation

57
Q

Goal met. Productive cough with moderate amount of thick, yellow sputum.

A

summative

58
Q

provides information about learning needs of clients and where additional instruction is needed.

it is designed to monitor activities with the purpose of improving the care plan.

A

formative

59
Q

provides information about learning needs of clients and where additional instruction is needed.

it is designed to monitor activities with the purpose of improving the care plan.

A

formative

60
Q

Continuing, modifying, or terminating the nursing care plan

A

evaluation phase

fundamentals of nursing (12 decks)

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