Test 2 Flashcards
Diagnosing
Analyzing patient data to identify patients strengths and problems
Assessing
Collecting, validating and communicating of patient data
Planning
Specifying patient outcomes and related nursing interventions
Implementing
Carrying out the plan of care
Evaluating
Measuring extent to which patient achieved outcomes
Nursing knowledge
Comes from a variety of sources maybe traditiona,l authoritative or scientific
Traditional knowledge
Nursing practice passed down from generation to generation
Authoritative knowledge
Comes from an expert and is accepted as truth based on the persons perceived expertise
Scientific knowledge
Knowledge obtained from the scientific method through research also known as evidence-based practice
Nursing theory
Serves the purpose of describing, explaining, predicting and controlling desired outcomes of nursing care practices
For concepts that determine nursing practice are?
the patient, the environment, health, nursing
Nursing research
Encompasses both research to improve the care of people in the clinical setting and also the broader study of people in the nursing profession, including studies of education, policy development, ethics, and nursing history
Evidence-based practice
Problem-solving approach to making clinical decisions using the best evidence available
PICO
P-Patient, population or problem of interest I-Intervention C-Comparison O- Outcome
Systematic
Part of an ordered sequence of activities
Dynamic
Great interaction and overlapping of the five steps
Interpersonal
Humans are always at the heart of nursing
Outcome oriented
Nurses and patients work together to identify outcomes
Universally applicable
A framework for all nursing activities
Characteristics of the nursing process
Systematic, dynamic, interpersonal, outcome oriented, universally applicable
Cognitive skills
Make sense of the situation and grasp what is necessary to achieve goals
Technical skills
Manipulate equipment skillfully to produce desired outcome
Interpersonal skills
Establish and maintain caring relationships that facilitate achievement of goals
Ethical/legal skills
Personal moral code and professional role responsibilities
Four types of nursing assessment
Comprehensive initial, focused, emergency, time-lapsed
Comprehensive initial assessment
Performed shortly after admitted to hospital is used to establish a complete database for problem identification and care planning
Focused assessment
Maybe performed during initial assessment or as routine ongoing data collection Gather data about a specific problem already identified
Emergency assessment
Performed to identify life-threatening problems Performed when a physiologic or psychological crisis presents
Time-lapsed assessment
Compare a patient’s current status to baseline data obtained earlier Reassess health status and make necessary revisions in plan of care
Four phases of a nursing interview
Preparatory phase, introduction, working phase, termination
Objective data
Observable and measurable data that can be seen, heard or felt by someone other than the person experiencing Ex elevated temp, vomiting
Subjective data
Information perceived only by the affected person ex pain, feeling dizzy, feeling anxious
Direct questions
Validate or clarify information
Reflective questions
Encourage patient to elaborate on thoughts and feelings
Open ended questions
Allow the patient to verbalize freely
Closed questions
Elicit specific information
When to verify data
When there’s a discrepancy between what the person is saying and what the nurse is observing when the data lack objectivity
Nursing diagnosis
Describes patient problems nurses can treat independently
Medical diagnosis
Describes problems for which the physician direct the primary treatment
Collaborative problems
Managed by using physician prescribed and nursing prescribed interventions
Four steps of data interpretation and analysis
Recognizing significant data, recognizing patterns or clusters, identifying strengths and problems, reaching conclusions
Nursing diagnosis PES
Problem Etiology Signs and symptoms
Benefits of nursing diagnoses
Individualized patient care defined domain of nursing to healthcare admin, legislatures and providers seek funding for nursing and reimbursement for nursing services
Initial planning
Developed by the nurse who performs the nursing history and physical assessment addresses each problem listed in the nursing diagnosis identifies appropriate patient goals and related nursing care
Ongoing planning
Carried out by any nurse who interact with patient, keeps the plan up to date, develops new diagnoses ,identifies nursing interventions to accomplish patient goals
Discharge planning
Carried out but the nurse who worked most closely with the patient, begins when the patient is admitted for treatment, uses teaching and counseling skills to ensure home-care behaviors are performed competently
High priority nursing diagnosis
Greatest threat to patient well-being
Medium priority nursing diagnosis
Non-threatening diagnosis
Low priority nursing diagnosis
Diagnoses not specifically related to current health problems (risk diagnosis)
Cognitive outcome
Describes increases in patient knowledge or intellectual behaviors
Psychomotor outcome
Describes patients achievement of new skills
Affective outcome
Describes changes in patients values, beliefs, and attitudes
Physiological outcome
Related to physical status of patient
Etiology
What causes the problem
