Test 2 Flashcards
What is the nursing process in order?
ADPIE (Assessment, Diagnosis, Planning, Implementing, Evaluating)
The type of knowledge that is based on scientific facts (akin to the knowledge found in a textbook).
Theoretical Knowledge
The type of knowledge which involves what to do and how to do tasks and skills safely.
Practical Knowledge
The type of knowledge that includes our own preferences or biases that may influence our thinking.
Self-Knowledge
Which knowledge is based on HOW to do something.
Practical Knowledge
Which knowledge is based on what to do and why to do it?
Theoretical Knowledge
What knowledge is based off of experiences?
Self-Knowledge
What knowledge helps a person handle situations where there is an element of right and wrong?
Ethical knowledge
This type of data comes directly from the patient.
Subjective data
This type of data is quantitative data or observable that is easily measured.
Objective data
This type of data can be deemed as “factual.”
Objective data
This part of the nursing assessment is the data gathering.
Assessment
This type of assessment is initiated upon first contact with a patient.
Initial assessment
This type of assessment is continuing the plan of care.
Ongoing assessment
This type of assessment explores the patient’s single complaint or symptom (often focuses on the primary concern).
Focused assessment
This type of assessment includes information about a person’s social and situational status, home support systems, holistic assessment of the patient’s beliefs and spiritual needs, what kind of assistance the patient has, and if the patient needs a discharge.
Comprehensive assessment
If information comes from another source than the patient, it is considered a ________ source.
Secondary
If the information comes directly from the patient, it is considered a __________ source
Primary
The statement of client health status that nurses can identify, prevent, or treat independently.
Nursing diagnosis
What is the major difference between nursing and medical diagnoses?
Medical is narrow; Nursing is broad. Nursing diagnoses are customizable to the patient’s individual needs.
What are the five types of nursing diagnoses?
- Actual
- Potential
- Collaborative
- Wellness
- Syndrome
What type of diagnoses are a predetermined cluster of nursing diagnoses that occur together? (Chronic Pain Syndrome)
Syndrome Diagnoses
What type of diagnoses are not identifying a problem but rather an area for improvement or to support health behaviors that are already happening? (Readiness for enhanced nutrition)
Wellness Diagnoses
What type of diagnoses address a problem with the probably cause and observable evidence? (Impaired swallowing related to sore throat)
Actual Diagnoses
What type of diagnoses focuses on problems that a patient may not have ye, but are clearly at risk for developing? (Risk for Falls)
Potential Diagnoses
What type of diagnoses requires collaboration with a provider to get orders in place?
Collaborative Diagnoses
What are the steps of developing a nursing diagnosis?
ADPIE
What is a PES statement?
Problem-Etiology-Symptoms
How does a PES statement work?
Problem (related to) etiology (as evidenced by) symptoms
What is the first part of the nursing diagnosis statement?
The NANDA label
What is the second part of the nursing diagnosis statement?
The etiology
What is the third part of the nursing diagnosis statement?
Evidence supporting your diagnosis or symptoms the patient is manifesting
What is a three part nursing diagnosis statement called?
A PES statement
What the five Maslow’s Hierarchy of Needs?
- Physiological Needs (Most Important)
- Safety Needs
- Belongingness and Love
- Esteem Needs
- Self-Actualization (Least Important)
What are the two main ways to prioritize the patient’s needs?
- ABC’s
2. Maslow’s Hierarchy of Needs
Which is higher priority out of acute vs chronic?
Acute
Which is the higher priority out of actual vs potential?
Actual
Critical thinking is the process of ______ ______.
Problem Solving
Theoretical knowledge is ______ based, whereas practical knowledge is knowing _____ to do a task properly.
science; how
________ may not be delegated to an assistive personnel.
Assessment
A head-to-toe assessment done during every shift is an example of what kind of assessment?
Ongoing
Does a focused assessment always only focus on one body system?
No
Which type of assessment evaluates the potential presence of domestic violence?
Psychosocial
Vital signs using a Dinamap are an example of what kind of data? Coming from what kind of source?
Objective; Secondary
Patient’s blood pressure is elevated, so the nurse checks with the patient to assess for a probable cause is what?
Validation
What will help the nurse to make sure that they gather all the necessary information to make an informed decision and draw correct conclusions?
Having a questioning attitude
The process of analyzing data, identifying patterns, and drawing conclusions.
Diagnostic Reasoning
True or False: There will always be exactly one nursing diagnosis for every medical diagnosis
FALSE
Nursing diagnoses are judgments based on ______ made in our nursing assessments.
Inferences
How many nursing diagnoses are there?
234
What type of nursing diagnosis only uses the NANDA label (problem statement) and an evidence statement?
Wellness diagnosis
What type of nursing diagnosis only uses the problem statement and etiology?
Potential Diagnosis (Risk For)
When would you include a “secondary to” statement?
When we are pointing out that we are address the collateral health manifestation and not the prevailing condition
What is the primary concern in Maslow’s Hierarchy of Needs?
Physiological (What is going to kill your patient the fastest?)
Love and belonging is what level of Maslow’s?
Third
Nursing diagnosis is always the result of a nursing ___________.
Assessment
What are continuous and change over time?
Plans
Predictions of changes in a patient’s health status that we expect the patient to achieve.
Expected Client Outcome (ECO)
ECO is always written in the terms of _____ ______.
Patient activity
In an ECO, what always must be the priority?
The Patient
What drives the ECO statement?
The NANDA problem and symptoms
What is the SMART mnemonic used for?
To narrow in your ECO goal.
What does SMART stand for?
Is the goal: S: Specific M: Measurable A: Attainable/Achievable R: Relevant/Realistic T: Time Bound
If a nurse delegates a task to an aid or NCP, who is responsible for making sure the task gets completed?
The nurse
Short term ECOs usually take place for how long?
During the admission of the patient
What type of intervention are those that nurses can put into place without the guidance of a provider? (Ex: ambulating a patient)
Independent intervention
What type of intervention involves collaboration with ancillary staff? (Ex: utilizing physical therapy)
Interdependent intervention
What type of intervention requires a provider order? (Ex: medications and diagnostics tests)
Dependent intervention