Unit Two Test Flashcards
when you gather history and physical assessment
assessment phase
putting plan into action
implementation phase
did the outcome come out as wanted
evaluation phase
what is the pneumonic for steps in nursing proccess
ADPIE assessment diagnosis planning implementation evaluation
assessment is ________
ongoing
what do you first assess
chief complaint
maslow’s hierarchy
physiological needs safety needs love and belonging esteem needs self actualization
actual problem=
ongoing problem
not as important because has not happened yet=
risk for
sex is located in what stage and why
physiological need because something has happened and lost participation in physical activity for a while
what are the 3 parts of formulating a nursing diagnosis
problem statement
etiology
defining characteristics
what is the pneumonic used for nursing diagnosis
PES
problem
etiology
signs and symptoms
avoid using ______ diagnosis with nursing diagnosis statement
medical
what is the first step in any plan
establish patient outcome
an outcome statement should have
objective, observable patient behaviors which are MEASURABLE and REALISTIC
planning needs to be
specific
outcome will need to start with
“the patient will..”
outcomes can be
short or long term
when planning outcome what is the pneumonic used
SMART specific measurable (quantity, freq, weight) attainable realistic time limited (short term/ long term)
planned treatments and actions that are performed to help the patient to reach the outcomes that are set for them
nursing interventions
no order needed=
independent nursing interventions
in conjunction with an interdisciplinary team member
interdependent nursing interventions
require an order
dependent nursing interventions
your actions you are going to perform to help patient reach goal will always start with
” the nurse will…”
interdependent is when working with
nutrition, physical therapy etc
carrying out nursing interventions
implementation
while implementing you need to
include your patient
who should evaluate
author of the plan of care
nurses responsible for pt care
healthcare team
the patient too
fecal impaction
may or may not need an order
need what parts of brain for critical thinking
both sides
what separates professional nurses form technical and ancillary staff
clinical decision-making skills
“its true because I believe it”
innate egocentrism
“its true because we believe it”
innate socioecentrism
“its true because I want to believe it
innate wish fulfillment
“its true because I have always believed it”
innate self-validation
“its true because it is in my selfish interest to believe it”
innate selfishness
purposefully thinking back on a situation to discover purpose or meanign
reflection
nurse who engages in critical thinking is also to express ideas and thinking in clear and precise terms, articulate
language
the direct understanding of particulars in a situation without conscious deliberation
intuition
attitudes for critical thinking
responsibility, disciplined, integrity
what should you never use when documenting
white out
erasable ink
obliterate
NO pencils
summary worksheet reference of basic information that traditionally is not part of the record
Kardex
vertical or horizontal columns for recording dates and times and related assessment and intervention information
flow sheets/forms
in a court of law “care not documented is
care that was not provided”
why would it be a reason to document refusal of medication
because it looks like you forgot to give it and will be accused of not doing your job
how would you correct errors
single line through entry error and your initials
how would you enter a late entery
add the entry to the first available line and label “late entry” (in body of entry add what time it was supposed to be entered and also add what time it is your entering data now
