Test 2 Study Guide Flashcards
The nursing process is an organized sequence of
problem-solving steps used to identify and manage the health problems of client
Be able to identify the steps of the nursing process and what is done during each step.
Assessment
1st step
When does the assessment begin?
Assessment begins with the nurse’s first contact with a client and continues as long as a need for health care exists. During assessment, the nurse collects information to determine areas of abnormal function, risk factors that contribute to health problems, and client strengths
observable and measurable facts and are referred to as signs of a disorder. An example is a client’s blood pressure measurement
Objective Data
information that only the client feels and can describe, and these are called symptoms. An example is pain.
Subjective Data
Diagnosis is what step
2nd step
What are we identifying with diagnosis?
The identification of health related problems
A Nursing Diagnosis is a health issue
is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility
Nursing Diagnoses are written to describe _____ nurses can ________.
Nursing Diagnoses are written to describe ___patient problems__ nurses can __solve______.
R/T
Related to
AEB
As evidence by
RF
Risk for
4th step of nursing process
Planning
To determine priorities nurses use
Maslow’s Hierarchy of Human Needs
Self actualization
Esteem needs
Social needs
Safety needs
Basic needs
Define Goals for planning
outcome criteria, identify specific evidence for each nursing diagnosis that a client’s problem is trending towards resolution or has been resolved
Explain short term goal
(outcomes achievable in a few days to 1 week) more often in acute care setting because most hospitals stays are only a few days or no longer 1 week
5 Characteristics: of planning
1 Developed from the problem portion of the diagnostic statement
2 Client-centered, reflecting what the client will accomplish, not what the nurse will accomplish
3 Measurable, identifying specific criteria that provide evidence of goal achievement
4 Realistic, to avoid setting unattainable goals, which can be self-defeating and frustrating
5 Accompanied by a target date for accomplishment (the predicted time when the goal will be met), which establishes a timeline for evaluation
Implementation is the _______ of nursing process
5th step
It means carrying out a
plan of care
Evaluation is the _____ step of nursing process
6th step
On evaluation has you patient reached________
Reached their goal
Are ideals that a person feels are important knowledge, wealth, financial security, martial fidelity, health
Values
Are concepts that a person holds to be true. Beliefs and values guide a persons actions
Beliefs
Means a full and balanced integration of all aspects of healthcare
Wellness
the aum of physical, emotional, social, and spiritual health. Determines how “whole” or well a person feels
Holism
What is Maslow’s Hierarchy of human needs? How do nurses use this tool? And Why?
( factors that motivate behavior) Physiologic ( first level), safety and security ( second level), love and belonging ( third level), esteem and self esteem ( fourth level) , and self actualization( fifth level)
is a state of being unhealthy when disease, deterioration, or injury impairs a person’s well being.
Illness
one that comes on suddenly and lasts a short time) is one method for classifying a change in health
Acute Illness: Onset
Sequelae ill effects that result from permanent or progressive organ damage caused by a disease or its treatment
Lasts
one that comes on slowly and lasts a long time) risk increases as people age
Chronic Illness: Onset
(one in which there is no potential for cure) is one that eventually is fatal. The terminal stage of an illness is one in which a person is approaching death.
Lasts Terminal Illness
(Incidence of a specific disease, disorder, or injury) refers to the rate or the number of people affected.
Morbidity: refers to the
Incidence of deaths) denotes the number of people who died from a particular disease or condition
Mortality: refers to the number of people who
one that develops independently of any other disease
Primary Illness
disorders that develop from a pre-existing condition.
Secondary Illness
is the disappearance of signs and symptoms associated with a particular disease
Remission
(reactivation of a disorder , or one that reverts from a chronic to an acute state) can occur periodically in clients with long standing diseases
Exacerbation
( disorder acquired from the genetic codes of one or both parents) may or may not produce symptoms immediately after birth.
Hereditary
(those present at birth but which are the result of faulty embryonic development) cannot be genetically predicted.
Congenital
is an illness of unknown case. Treatment focuses on relieving the signs and symptoms because the etiology is unknown
Idiopathic
