Nursing Process PPT Flashcards
______ decision making requires critical thinking.
clinical
Clinical decision making requires critical thinking. This separates professional nurses from technical and ______ staff.
ancillary
Nurses need to seek knowledge, act quickly, and make sound ______.
clinical decisions
Nurses are guided by ____ to become an informed critical thinker.
EBP (evidence based practice)
Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each _____ patient situation and determine which identified assumptions are true and relevant.
unique
_______ is recognizing that an issue exists, analyzing information, evaluating information, and making conclusions
critical thinking
Critical Thinking Skills (6)
Interpretation Analysis Inference Evaluation Explanation Self-Regulation
Nurses use the nursing process to determine client/family level of wellness and ________.
need for assistance
Nurses use the nursing process to _______ (physical and emotional)
provide care
Nurses use the nursing process to teach, guide and ______
counsel
Nurses use the nursing process to implement _______ aimed at prevention and assisting the client to meet his or her needs.
interventions
The nursing process is a variation of ______.
scientific reasoning
The five steps of the nursing process allow you to be organized and have a _______.
systematic approach
The five steps of the nursing process allow you to learn to make ______ about the meaning of a patient’s response to a health problem or generalize about the patient’s functional state of health.
inferences
By using the nursing process, in particular the assessment portion, a ____ begins to form.
pattern
The five steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
During the assessment you collect information from primary and ______ sources.
secondary
During ______ you gather the “patient’s story” along with interpreting and validating the information to form a complete database.
assessment
The primary source to collect information from is the ____. Every time a piece of information is added to the health record it becomes another part of the “patient’s story”
patient
The secondary source of information can come from _______, friends, other health care providers, scientific literature, and the nurse’s experience.
family members
The purpose of assessment is to establish a _____. This includes patient’s perceived needs, health problems, and _______.
database
responses to these problems
Critical thinking skills help you to synthesize relevant information and use it is a _____ way.
purposeful
During the assessment you gather information and it includes information from the _____.
physical examination
During the assessment, collect data. With this information ______ cues, then make inferences. Identify patterns and problem areas.
cluster
Interview Techniques (3)
open-ended vs closed ended questions
back channeling
probing
Because a patient’s report includes subjective information, ____ data from the interview later with objective data.
validate
Obtain information (as appropriate) about a patient’s physical, ______, emotional, intellectual, social, and spiritual dimensions.
developmental
Information about work, _____ and home surroundings comes from a thorough health history.
social
____ is when you gather information about the patient’s condition.
assess
____ is when you determine if goals and expected outcomes are achieved.
evaluation
_____ is when you perform the nursing actions identified in planning.
implementing
___ is when the nurse identifies the patient’s problems.
diagnose
_____ is when you set goals of care and desired outcomes and identify appropriate nursing actions.
planning
There are two stages of assessment which include the collection and verification of data as well as the _____.
analysis of data
The analysis of data includes recognizing patterns or trends, compare the data with expected standards and reference ranges, and arrive at conclusion to _______.
guide nursing care
_____ information is obtained from teh client - patient’s feelings, perceptions, and reported symptoms.
subjective
____ information is obtained from the physical assessment, vital signs, laboratory and diagnostic results, patient’s behavior, observations made.
objective
Two comprehensive Assessment Approaches
general to specific
problem oriented approach
_______ is a visual representation that allows nurses to graphically illustrate the connections between a patient’s health problems
concept mapping
Concept mapping allows nurses to obtain a______ perspective of health care needs
holistic
To conduct an accurate and complete assessment, you need to consider a patient’s ______ background.
cultural
When cultural differences exist between you and a patient, respect the _____ and be sensitive to a patient’s uniqueness.
unfamiliar
If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong _____.
diagnostic conclusion
If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong _____.
diagnostic conclusion
NANDA stands for
North American Nursing Diagnosis Association
_______ allows the nurse to select relevant and appropriate nursing interventions
nursing diagnostic statements
Nursing diagnostic statements provides a _______ of a patient’s problem that gives the health care team a common language for understanding patients’ needs.
precise definition
A _________ allows nurses to communicate what they do among themselves and with other health care professionals and the public.
nursing diagnostic statement
A nursing diagnostic statement distinguishes the nurse’s role from that of the _______.
physician or other health care provider
A nursing diagnostic statement helps nurses focus on the ____ of nursing practice.
scope
Identification of a disease condition based on specific evaluation of signs and symptoms is considered a _____ diagnosis.
medical
Clinical judgment about the patient in response to an actual or potential health problem is considered a _____ diagnosis.
nursing
Actual or potential physiological complication that nurses monitor to detect a change in patient status is considered a ____.
collaborative problem
Describes human responses to health conditions or life processes is the _____ diagnosis which exists already.
nursing
Describes human responses to health conditions/life processes that may develop which has the _____ or “risk for” nursing diagnosis.
potential
A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential is considered the ________ nursing diagnosis.
health promotion
What are the 3 parts to developing a Nursing Diagnosis?
- Diagnostic Label (approved by NANDA)
- “Related to” factor (etiology; causative factor for the diagnosis)
- Evidence or Defining Characteristics
“Risk for” does not have evidence
When developing a ______ you use the diagnostic reasoning process which involves using the assessment data you gather about a patient to logically explain a clinical judgment or the diagnostic label for a nursing diagnosis..
nursing diagnosis
Cluster data and identify _____ and problems to develop a Nursing Diagnosis such as impaired skin integrity and risk for impaired skin integrity.
patterns
______ factors are pertinent to the diagnoses.
related to
Developing a nursing diagnosis allows you to _______ the diagnosis for a specific patient.
individualize
When you are ready to form a plan of care and select nursing _______, a concise nursing diagnosis allows you to select suitable therapies.
interventions
______ are clinical criteria or assessment findings used in developing a nursing diagnosis.
Symptoms
Data clusters are patterns of data that contain defining characteristics are considered clinical criteria that are observable and _____.
verifiable
A ______ is a set of signs or symptoms gathered during assessment that you group together in a logical way.
data cluster
Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a _____.
diagnostic conclusion
Impaired….. r/t immobility as evidenced by (AEB) disruption of epidermal and dermal skin of the right heel.
?
Diagnostic Statement Guidelines
- Identify the patient’s response, not the medical diagnosis.
- Identify a NANDA-I diagnostic statement rather than the symptom.
- Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention.
- Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
- Identify the patient response to the equipment rather than the equipment itself.
- Identify the patient’s problems rather than your problems with nursing care.
- Identify the patient problem rather than the nursing intervention.
- Identify the patient problem rather than the goal of care.
- Make professional rather than prejudicial judgments.
- Avoid legally inadvisable statements.
- Identify the problem and its cause to avoid a circular statement.
- Identify only one patient problem in the diagnostic statement.
_____ contains two parts: write measurable patient/client outcomes (PO) and
Identify nursing interventions to accomplish the outcomes (PI)
Planning
The _______ and interventions are designed to change the client’s nursing diagnosis/problem.
patient outcomes
