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Med Surge 112 > Nursing Process Powerpoint > Flashcards

Nursing Process Powerpoint Flashcards

1
Q

Preventing illness, promoting, maintaining, restoring health, maximizing sense of well-being, maximizing pt’s ability to function in desired role, provide cost-effective; efficient care, improve pt satisfaction are all…

A

goals of nsg

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2
Q

Asking questions, evaluating data, identifying assumptions, examining alternatives, and seeking understanding of different points of view are all components of what:

A

components of critical thinking

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3
Q

Organizing and prioritizing INDIVIDUALIZED pt care, providing a focused/holistic care, forming problem-solving skills, minimizing errors or omissions are all completed by utilizing what critical thinking tools of the nsg process:

A

purposeful/systematic and interpersonal/collaborative

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4
Q

What are the five steps of the nsg process:

A

ADPIE: assessment, dx, planning, implementation, evaluation

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5
Q

The nsg process is:

A

dynamic, requires creativity in its application, utilizes the same steps but may result differently w/each pt, designed for use in any care setting, involves overlapping steps

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6
Q

Collecting, organizing, clustering, identifying, documenting, and formulating goals are all included in what step of the nsg process:

A

assessment

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7
Q

To establish a database-allows for accessibility to all members of the health team, pt’s responses to health concerns or illnesses, pt’s ability to manage health care needs-and is continuous throughout all steps is the purpose of what step of the nsg process:

A

assessment

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8
Q

Data collection occurs in what 3 phases:

A

before you see the pt, when you see the pt, and after you see the pt

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9
Q

What are the 4 types of assessment:

A

initial, problem-focused, emergency, and time-lapsed

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10
Q

This type of assessment is the complete database for problem identification and is the baseline data for comparison:

A

initial assessment: admission assessment

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11
Q

This type of assessment determines the status of a specific problem:

A

problem-focused assessment: hourly I&Os

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12
Q

This type of assessment identifies life-threatening problems:

A

emergency assessment: airway assessment

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13
Q

This type of assessment compares pt’s current status to baseline data previously obtained:

A

Time-lapsed: reassessment

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14
Q

Data that’s apparent only to the person affected, that can be described only by the person affected (sensations, feelings, values, beliefs, attitudes, perceptions of personal health status) is defined as:

A

subjective data/covert data

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15
Q

Data that’s only detectable by an observer, that can be measured or tested against an accepted standard, can be seen, heard, felt, or smelled, and obtained physical examination is defined as:

A

objective data/overt

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16
Q

Primary data are sources from:

A

the pt only

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17
Q

Secondary sources are from:

A

everybody else other than the pt

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18
Q

What are the three methods of data collection:

A

observing, interviewing, examining

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19
Q

Gathering data using the senses to obtain skin color, oders, lung/heart sounds, skin temperature all falls under

A

observation

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20
Q

A planned communication or a conversation w/a purpose to obtain or give info, to evaluate change, to teach, to provide support, and to provide counseling falls under:

A

interviewing

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21
Q

What type of questioning promotes dialogue, reveals what is important to pt, reveals lack of understanding, and shows heartfelt interest:

A

open-ended questioning

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22
Q

What type of questioning clarifies responses, saves times, focuses the interviews, is utilized with sicker pts, and easily documented:

A

close-ended questions

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23
Q

What does oldcart stand for:

A

onset, location, duration, characteristics, aggravating factors, relieving factors, and TX

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24
Q

What type of examination includes: systematic-data collection method (heat-to-toe), techniques (observation, inspection, and auscultation), data obtained (V/S, head-to-toe)…

A

physical examination

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25
Q

What are you doing to data when you identify nsg dx/problems, identify S/S of possible medical problems, setting priorities (ABCs, Maslow’s hierarchy), promoting critical thinking, and identifying pt’s strengths:

A

when clustering/organizing data of the ________ in the nsg process

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26
Q

To compare subjective & objective data (conflicting info), comparing to rule out unreliable sources, and to recheck abnormal findings (comparing findings to normal values) is to what with data?

A

validating data

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27
Q

What are the types of nsg assessment frameworks:

A

nsg model/framwork=Neuman Model; non-nursing models=body systems mode/Maslow’s Hierarchy of Needs/and developmental theories

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28
Q

Timely reporting promotes:

A

expedited dx, TX of urgent problems, continuity of care, and accurate documentation

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29
Q

Timely reporting, continuity of care, accurate documentation occur when doing what with data:

A

reporting or recording data

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30
Q

Analyzing data, identifying (health problems, risks, strengths), and formulating dx TX are all steps to:

A

dx steps

31
Q

What organization is internationally recognized as the leader in development ad classification of nsg dx

A

North American Nsg DX Association (NANDA)

32
Q

What are the nsg dx components:

A

P=problem, E=etiology, S=S/S (e.g., (P) deficient fluid volume r/t (E)insufficient intake to replace fluid loss as evidenced by (S) tachycardia and poor skin tugor

33
Q

When writing correct nsg dx…

A

…use nsg terminology and avoid medical terminology and never apply legal liability such as “impaired skin integrity r/t IMPROPER POSITIONING

34
Q

Normal functions of the body such as acute pain, impaired physical mobility, risk for aspiration…, are what type of dx?

A

physiological DX

35
Q

Mental or emotional info such as self-esteem disturbance, anxiety, fear, social isolation are what type of DX?

A

psychological dx

36
Q

Problems w/anatomy or physiology that may arise because of current dx, tx, or invasive dx studies or monitoring that requires early recognition of s/s and identifying your pt’s current problem is defined as:

A

potential complications

37
Q

What’s the difference between risk dx and PC dx:

A

risk dx requires only nsg interventions (2 part statement)whereas PC requires nsg and medical interventions

38
Q

A nsg dx that’s associated w/a cluster of other diagnosis is called:

A

syndrome nsg dx with one part statement

39
Q

What type of dx identifies conditions the doctor is licensed & qualified to treat/focuses on the illness, injury, or disease process/remains constant until a cure occurs:

A

medical dx

40
Q

What type of dx identifies situations the nurse is licensed to treat/focuses on the pt responses to actual or potential health problems/evolves as the pt’s responds &/or health changes:

A

nsg dx

41
Q

What part of the nsg process begins w/first pt contact, continues until the nurse-pt relationship ends, is multidisciplinary, and documenting NCP in medical record…

A

Planning

42
Q

These activities are what part of the nsg process: prioritizing problems and dx, formulating goals and desired outcomes, and formulating individualizing nsg interventions…

A

planning

43
Q

What are the three types of planning:

A

initial planning, ongoing planning, and discharge planning

44
Q

What type of planning anticipates and prepares for the pt’s needs after effective TX:

A

discharge planning

45
Q

What type of planning includes updates of care based on reassessment:

A

ongoing planning

46
Q

What type of planning develops the preliminary plan of care

A

initial planning (on admission)

47
Q

Providing direction for planning nsg interventions/serving as criteria for evaluating pt progress/motivating pt by providing a sense of achievement/ and is derived from ONE nsg dx all fall under the purpose of…

A

goals/desired outcomes

48
Q

Pt goals…

A

…describes what the pt needs to achieve, and is pt centered (THE PT will accurately DEMONSTRATE a dressing change by 1400)

49
Q

What are the 3 parts to a correctly written goal statement:

A

GTT: G=goal statement is written as “the pt will…”, T=tool for measuring goal achievement is part of the statement (“…as measured by…”), T=time for evaluating goal achievement is part of the statement (“…by noon today…”)

50
Q

Writing goal statements requires utilizing ROAM. What does ROAM stand for:

A

R=realistic, O=observable, A=achievable, M=measurable

51
Q

What are the types of measurable verbs for pt goals:

A

cognitive domain (teach, identify), affective domain (express, communicate), psychomotor domain (demonstrate, walk)

52
Q

What are the types of non-measurable verbs:

A

know, think, understand, feel

53
Q

What type of goal describes early, expected benefits of nsg interventions:

A

short-term goals

54
Q

“The pt will walk independently to the end of the hall 3 times a day within 10 days after surgery.” is an example of what type of goal?

A

long-term goal

55
Q

What type of goal describes the benefits expected to be seen at a certain point in time after the plan has been implemented:

A

long-term goal

56
Q

“The pt will walk to the bathroom unassisted by 1400 today.” is an example of what type of goal:

A

short-term goal

57
Q

The rule of thumb when writing NCP:

A

include date and time for each goal, be specific (don’t write “at end of shift”), tailor the plan to your pt’s daily routine, include preventative and health maintenance interventions (not just restorative), include plans for discharge/home care needs

58
Q

What part of the nsg process includes monitoring health status, reducing risks, resolve/prevent/or managing problems, facilitate independence, and promoting optimum sense of physical/psychological/spiritual well-being:

A

implementation

59
Q

What are the types of nsg interventions:

A

direct (through direct interaction such as teaching diabetes) and indirect (away from, but on the behalf of the pt such as monitoring labs or contacting a social worker)

60
Q

This nsg intervention are nsg actions initiated by the nsg is defined as:

A

independent nsg intervention

61
Q

This nsg intervention are actions implemented by the nurse in conjunction w/other health care professionals is defined as:

A

interdependent nsg intervention

62
Q

This nsg intervention requires a physician’s order is defined as:

A

dependent nsg intervention

63
Q

What are the 4 parts to nsg orders when writing the NCP:

A

Assess, DO, Teach, Document

64
Q

What phase of the nsg process includes: reassessing the pt, determining the need for assistance, initiating nsg interventions, supervising delegated care, and documenting nsg activities…

A

implementation phase

65
Q

What of implementation is documented:

A

the nsg activities & pt responses for nsg actions; individualized nsg activities based on assessment data; past-tense=what the nsg did and the pt’s response to the nsg intervention

66
Q

Successful implementation includes what type of skills:

A

cognitive skills (knowledge), interpersonal skills (communication), and technical skills (psychomotor)

67
Q

What are the four professional implications in the utilization of the nsg process:

A

1=identifiers of consumer care (ganey survey and internet); 2=Standards of Nsg Practice; 3=BRN mandates the use of the Nsg process; 4=National Practice Standards states RN accountability of the Nsg process

68
Q

What are maslow’s needs and write them in accordance to importance:

A

5 needs: physiological needs, safety/security; love/belonging; self-esteem; self/actualization (refer to powerpoint)

69
Q

Inorder to set priorities to address nsg dx/interventions, you need to know the 3 most common types of priorities. What are they:

A

High-priority=life threatening; Medium priority=health threatening; and Low priority=developmental needs

70
Q

Each pt goal is derived by how many nsg dx:

A

one nsg dx

71
Q

Goals focus on: pt or nsg?

A

the pt

72
Q

Outcomes focus on: pt or nsg?

A

nsg

73
Q

What is written in the NCP in order to resolve, prevent, and manage problems for pts:

A

nsg interventions

Med Surge 112 (3 decks)

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