Unit 1 Flashcards
Problem-focused dx
Describes existing problem
Risk dx
Describes potential prob that pt is vulnerable to
Risk for _____ r/t _________
Health Promotion dx
Describes pt’s, family’s or community’s desire to realize human health potential. Focus = being as healthy as possible.
Ex: Effective breastfeeding
Syndrome dx
Group of S&S that occur together
Ex: Sleep deprivation
Characteristics of Critical Thinkers
- Raise Q’s
- Willingness to search for answers
- Inquisitive
- Eager to acquire new knowledge
- Consider multiple perspectives
- Explore ideas/problems in new ways
- open-minded
What is Critical Thinking
character + knowledge + skills
What is the Nursing Process
Problem-solving process
ADPIE
Assessment Diagnosis Planning Implementation Evaluation
2 Types of data
Subjective (what a pt “says”)
Objective (measurable)
Secondary sources of data
Family, friends, caregivers, pt records, literature
Steps after assessment
- Cluster (like info together)
- Validate
- organize
- Document
What is etiology
problem + reason
Nursing diagnosis format?
Diagnostic label + related factors
Diagnosis formula =
problem + r/t + reason
impaired comfort r/t bld glucose testing
Planning:
1) initial
2) Ongoing
3) Discharge
Planning has what priority settings:
ABC’S
Airways, breathing, circulation, & safety
High, med, low
Characteristics of pt-centered goals (PLANNING)
Singular; observable; measurable; time-limited; mutual; realistic.
Short-term / long-term.
Simple
Word formula for planning
Combine verb with condition and criterion:
Ex: Patient will demonstrate minimal episodes of agitation
as evidenced by a calm demeanor over 48 hours
What do you always use with implementation
scholarly resources
During implementation when do you initiate interventions…after:
- Reassessing the pt
- Organize resources
- Anticipate/prevent complications
What is the evaluation focused on?
ONLY Pt and Plan
What is the evaluation NOT focused on
Nurses action
What part do you refer to during evaluation step?
The goal
What are the 3 Outcomes of goal?
- Goal met
- Goal partially met
- Goal not met
1.
According to the biomedical model, a narrow definition of health is:
a) an optimal functioning of mind, body, and spirit within the environment.
b) the absence of disease.
c) the response of the whole person to actual or potential problems.
d) prevention of disease.
B
2. What type of database is most appropriate when a rapid collection of data is required and is often compiled concurrently with life-saving measures? A. Episodic B. Follow-up C. Emergency D. Complete
C
- A medical diagnosis is used to evaluate:
A. a person’s state of health.
B. the response of the whole person to actual or potential health problems.
C. a person’s culture.
D. the cause of disease.
D
- Which of the following is considered an example of subjective data?
A. Decreased range of motion
B. Crepitation in the left knee joint
C. Left knee has been swollen and hot for the past 3 days
D. Arthritis
C
5. What type of database is most appropriate for an individual who is admitted to a long-term care facility? A. Episodic B. Follow-up C. Emergency D. Complete
D
6. Which of the following is considered an example of objective data? A. Alert and oriented B. Dizziness C. An earache D. A sore throat
A
- An example of objective data is:
A. complaint of left knee pain.
B. crepitation in the left knee joint.
C. left knee has been swollen and hot for the past 3 days.
D. report of impaired mobility from left knee pain as evidenced by an inability to walk, swelling, and pain on passive range of motion.
B
- A nursing diagnosis is best described as:
A. a determination of the etiology of disease.
B. a pattern of coping.
C. an individual’s perception of health.
D. a concise statement of actual or potential health concerns or level of wellness.
D
- A complete database is:
A. used to rapidly collect data and is often compiled concurrently with life-saving measures.
B. used for a limited or short-term problem usually consisting of one problem, one cue complex, or one body system.
C. used to evaluate cause and etiology of disease.
D. used to perform a thorough or comprehensive health history and physical examination.
D
- A patient admitted to the hospital with asthma has the following problems identified, based on an admission health history and physical assessment. Which problem is a first-level priority?
A. Ineffective self-health management
B. Risk for infection
C. Impaired gas exchange
D. Readiness for enhanced spiritual well-being
C
Which of the following statements about nursing diagnoses is true? Nursing diagnoses:
A. Evaluate the reason for a disease.
B. Are a process based on medical diagnosis alone.
C. Evaluate the response of the patient to actual or potential health problems.
D. Focus on the function and malfunction of a specific organ system in response to disease
C
What are the SMART Outcomes
Specific Measurable Attainable Realistic Time
4 major components of diagnostic reasoning
- Attending to cues (S&S, info, lab data)
- Formulating diagnostic hypotheses
- Gather data
- Evaluate hypothesis …leads to final diagnosis
Evidence-informed practice uses: (3) _______ to make decisions about care & treatment
- best evidence
- Clinician’s experience
- Pt’s preferences & values
Biomedical health model
Absence of disease
Behavioral Model
include primary and secondary prevention with emphasis on changing behaviour and lifestyle.
Socioenvironmental Model
biomedical + behavioural models + sociological and environmental aspects of health.
Social determinants of health
social, economic, and political conditions that shape the health of individuals, families, and communities.
Relational Approach to Nursing Practice
considers health and illness and the meaning they hold as being shaped by social, cultural, family, historical, and geographical as well as by the patient’s gender, age, ability, and other individual contexts.
Steps to setting priorities
- 1st level (ABC’S + V[vital sign concerns])
- 2nd level (mental status, acute pain, irregular lab, ect)
- 3rd level (lack of knowledge, rest, coping)
- Collaborative problems
