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NURS 234 > Patient Centered Care > Flashcards

Patient Centered Care Flashcards

1
Q

What is patient centered care?

A

Care based on each patient’s unique needs and understanding of the patient’s preferences, values and beliefs

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2
Q

What is the nursing process?

A

Is a problem solving approach to the identification and treatment of patient problems that is the foundation of nursing practice. A type of scientific reasoning.

The framework provides a structure for delivering nursing care and the knowledge, judgements and actions that nurses use to achieve the best patient outcomes. Continuous and cyclical.

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3
Q

What are the five steps of the nursing process?

A

Assess, Diagnose, Plan, Implement, Evaluate

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4
Q

What is Assessment?

A

Collecting a comprehensive set of data (subjective and objective data) about a patient and recognize and identify patterns that begin to reflect the meaning of a patient’s response to health care problems. Uses observation and interview

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5
Q

What are the three types of nursing assessments??

A

Patient centered interview - comprehensive nursing history (detailed assessment of a patient’s physical, psychosocial, cultural, spiritual, and lifestyle needs) ***comprehensive

Periodic Assessment - (conducted during ongoing contact with patients) collected during rounding or while you administer patient care include quick screenings to rule out or follow up on patient problems (incisional pain, post op confusion) ***problem focused

Physical Examination -
(conducted during nursing history and any time a patient presents a symptom) comprehensive review of all major body systems providing objective data about a patient’s clinical status

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6
Q

What is subjective and objective data?

A

Subjective - what the patient says

Objective - what the nurse observes

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7
Q

What is a nursing care plan?

A

A customized plan of care that includes nursing diagnoses, outcomes, and interventions. Adapted for each patient’s specific and unique health problems

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8
Q

What is an interprofessional care plan?

A

Includes contributions from all disciplines involved in patient care

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9
Q

What is a concept map?

A

Records the nursing process in a visual diagram.

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10
Q

What is a Health Care agency Care Plan?

A

With growth of Electronic Medical Records (EMR) documentation systems include software programs for individualized and standardized care plans

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11
Q

What is a collaborative problem?

A

Certain physiologic complications that nurses must monitor to detect onset of or changes in a patient’s status. Requires both medicine and nursing interventions to treat.

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12
Q

What is a conceptual care map?

A

blend a concept map and a nursing care plan

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13
Q

What are some sources of assessment sources of data?

A

Patient
Family caregivers
Significant others
Health care team
Medical Records (procedures, lab results, medications)
Other records (educational, military, employment records) *HIPPA protects access
Nurse’s experience

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14
Q

Nursing Diagnoses (2nd step of nursing process)

A

Analyzing the assessment data and identifying a nursing diagnosis or problem. (ANA) Nurse’s clinical judgement about the patient’s response to actual or potential health conditions or needs.

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15
Q

What are the two types of diagnosis:

A

Medical: identification of a disease condition based on specific evaluation of physical signs and symptoms, a patient’s medical history and the results of diagnostic tests/procedures

Nursing: a clinical judgement made by a nurse to describe a patient’s response or vulnerability to health conditions or life events that nurse is licensed and competent to treat. ***Treats patient’s responses to health conditions (ex. intervention to minimize pain or improve mobility)

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16
Q

NANDA (NANDA-1)

A

North American Nursing Diagnosis Association

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17
Q

NIC

A

Nursing Intervention Classification

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18
Q

NOC

A

Nursing Outcome Classification

19
Q

What is purpose of NANDA, NIC, NOC?

A

Improves communication among health care providers by using standard nursing terminology

20
Q

What are the three different types of nursing diagnostic statements and how are they defined?

A

problem focused (negative diagnoses) - identify an undesirable human response to existing problems (acute pain, urinary retention)

risk diagnosis - diagnoses that apply when there is increased potential and vulnerability for a patient to develop a problem or complication (risk for fall, risk for unstable BP)

health promotion (positive diagnoses) - identify the desire or motivation to improve health status through a positive behavioral change (readiness for enhanced relationship, family support)

21
Q

What is data clustering?

A

The review and analysis of assessment data involve critically organizing all data elements about a patient into meaningful patterns or data clusters (sets of assessment findings/defining characteristics)

-each data element is an objective or subjective sign, symptom or risk factor that leads you to make a diagnostic conclusion

22
Q

What is involved in data interpretation?

A

Interpretation: Uses “cues” or objective data and cluster this information that relates to make inferences and identify emerging patterns

Then validate the assessment to compare to another source to determine data accuracy

23
Q

What is clinical inference?

A

is the part of the clinical decision making process that occurs before you determine the patient’s problem (crying may mean sadness)

24
Q

What are the components of a problem focused nursing diagnosis?

A

3 parts - a diagnosis label, related factors, and major defining characteristics

25
Q

What are the components of a risk nursing diagnosis?

A

2 parts - a diagnosis and the associated risk factors preceded by the phrase “as evidenced by”

26
Q

What are the components of a health promotion nursing diagnosis?

A

2 parts - the diagnosis label and the defining assessment findings.

27
Q

What are basic components

A

diagnostic label - nursing diagnosis
related factors - etiologies, circumstances, facts or influenced response that have a relationship with the nursing diagnosis
Major assessment findings - further clarity is added to the nursing diagnosis statement if you list major assessment findings which offers a guide for how you will evaluate the efficacy of nursing care.

28
Q

Planning Nursing Care (3rd step of nursing process)

A

develop outcomes/ goals and identify nursing interventions to achieve these

*most important principle in planning is the individualization of a patient centered plan of care for each patient’s unique needs

29
Q

What is establishing priorities during the planning phase?

A

The ordering of nursing diagnoses/problems to establish a preferential order for nursing interventions

  • problem focused takes priority over wellness, possible risk and health promotion problems
  • short term acute takes priority over long term chronic needs
  • priority setting is not the ordering of a list of care tasks but an organization of the desired patient outcomes
  • By ranking a patient’s nursing diagnosis in order of importance and always monitoring changing signs/symptoms of a patient’s problems you attend to the patient’s most important need and better organize ongoing care. Same is true when taking care of a group of patients.
30
Q

What are some methods for prioritizing?

A
  • High, intermediate, low
  • If not treated causes harm (Airway, breathing, and circulation) = high priority
  • Prioritize according to Maslow’s Hiearchy of needs
  • Intermediate priorities are nonemergent and not life threatening
  • Low is not always directly related to a specific illness or prognosis but affect the patient’s future well-being
  • Involve the patient in priority setting (part of patient centered care)
31
Q

What kind of factors affect your ability to set priorities?

A
  • Experience and expertise of nurse
  • Patient acuity
  • Availability of resources
  • Interruptions from care providers
  • nurse-patient relationship
  • ward organization
  • priority setting strategies and frameworks
32
Q

The planning process is a dynamic process that changes as the patient’s needs change - True or False?

A

True

33
Q

Goals and expected outcomes are?

A

Specific statements of patient behavior or physiological responses that you select to resolve a nursing diagnosis/problem

Goal is an ultimate outcome and expected outcomes as the measurable changes that patient achieves to reach a goal

time limited

34
Q

What is the difference between a short term goal and a long term goal?

A

A short term goal is an objective behavior or response that you expect the patient to achieve in short time, usually less than week or for a few hours

A long term goal is an objective behavior or response that you expect a patient to achieve usually over several days, weeks, or months

35
Q

What is the SMART acronym to write goals and outcomes?

A
  • specific
  • measurable
  • attainable
  • realistic
  • timed
36
Q

What is Implementation in Nursing Care (4th step of nursing process)?

A

It involves the performance of nursing and collaborative interventions necessary to achieve goals/expected outcomes needs to support or improve patient’s health status.

37
Q

What is a nursing intervention?

A

any treatment based on clinical judgement and knowledge that a nurse performs to enhance patient outcomes.

38
Q

Direct care interventions

A

treatments the nurse provides through interactions with patients or a group of patients (medical administration, insertion foley, discharge instruction)

39
Q

Indirect care interventions

A

are treatments performed away from a patient on behalf of the patient or group (managing the environment, safety, infection control)

40
Q

What is a clinical practice guideline and protocol?

A

systemically developed set of statements about appropriate health care for specific health care problems or clinical situations

41
Q

What is a care bundle?

A

Group of interventions when implemented together, result in better patient outcomes than when interventions are implemented individually.

42
Q

What are standing orders?

A

A preprinted document containing medical orders for routine therapies, monitoring guidelines, and or diagnostic procedures for specific patients with identified clinical problems. It directs patient care in a specific clinical setting. (ex./ Cardizem for an irregular heart rythym)

43
Q

Nursing Interventions Classification Interventions

A

A system that offers a language that nurses can use to identify treatments nurses perform, organize information and provide communication that everyone can understand.

NURS 234 (2 decks)

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