Unit V (Nursing Process) Flashcards
Name the five steps of the nursing process.
1) Assessment
2) Diagnosis
3) Planning
4) Implementation
5) Evaluation.
The nurse is collecting data regarding the patients response patterns. What stage of the nursing process is the nurse in?
1) Assessment
The nurse is prioritizing problems related to the patients response patterns to form a plan of care. What stage of the nursing process is the nurse in?
3) Planning
The nurse has administered pain medication and later asks the patient if the medication was effective in relieving the pain. What step of the nursing process is the nurse in?
5) Evaluation
The nurse is analyizing the patients response patterns. What step of the nursing process is the nurse in?
2) Diagnosis
The nurse administers medication. What stage of the nursing process is the nurse in?
4) Implmentation
The nurse assists the patient to high fowlers position to relieve shortness of breath. What stage of the nursing process is the nurse in?
4) Implementation
The nurse asks that patient to point to the location of their pain and to rate it on a pain scale. What stage of the nursing proccess is the nurse in?
1) Assessment
The nurse concludes the blood pressure medication has not alleviated the patients hypertension. What stage of the nursing process is the nurse in?
5) Evaluation
The nurse writes: The pt will have improved gas exchange with expected responses of: absence of adventitious breath sounds. What stage of the nursing process is the nurse in?
3) Planning
The nurse identifies the pt to have fluid volume overload. What stage of the nursing process is the nurse iin?
2) Diagnosing
The nurse identifies the patient to have risk of falls. What stage of the nursing process is the nurse in?
2) Diagnosing
The nurse is listening to breath sounds to obtain a basline upon admission. What stage of the nursing process is the nurse in?
1) Assessing
The nurse writes: The nurse will assess for skin break down using the Braden Scale. What stage of the nursing process is the nurse in?
3) Planning
The nursing student lists the ‘RAT:’ for the nursing intervention. What stage of the nursing process is the nursing student in?
3) Planning
The nurse finds the patients dyspnea has improved after recieving the prescribed breathing treatment. What stage of the nursing process is the nurse in?
5) Evaluating
During the nursing process, what type of diagnoses are made? What type of diagnoses are to be avoided?
Nursing Diagnoses are made, Medical diagnoses are avoided.
When does the nursing process involve nursing outcomes and interventions for families?
- When family will be caregivers
- Newborn/Children (Pediatrics)
When does the nursing process involve nursing outcomes and interventsion for community?
-Preventative measures (Vaccinations/Screening)
A purpose of the nursing process is to identify patients _______ ______.
health status.
A purpose of the nursing processis to identify ______ or _______ health problems.
actual -or- potential
A purpose of the nursing process is to establish a _____ to meet ______ ______.
plan -to meet- identified needs
How is the nursing process organized?
according to the patients problems.
How is the nursing process interpersonal?
The nurse must communicate with the patient to meet their needs.
How is the nursing process collaborative?
Requires interaction with other members of the healthcare team to provide quality care.
When setting outcomes for the patient, who should the collaborate with? What idea does this encompass?
The patient. Idea: Patient Centered Care
What does NANDA stand for?
North American Nursing Diagnosis Association
How does NANDA focus their diagnoses?
Focus on the scope of nursing pracitce
What does NANDA serve to distinguish?
Distinguish the nurses role from the physicians.
The nurse is performing a procedure that has been proven effective through research. This type of practice is called:
Evidence based practice.
What does Evidence Based Practice intergrate?
Research with Clinical Practice
Items such as medication errors, near misses, and duplication of services are the focus of what group?
QI: Quality Improvement
True of False:
Quality Improvement and Evidence Based Practice go hand in hand.
True
Things done to prevent disease fall under what type of prevention?
Primary
Early detection measures that allow for prompt interventions fall under what type of prevention?
Secondary
Techniques used to manage the disease fall under what level of prevention?
Tertiary
List the examples of cues:
- What the pt says
- What the nurse can see, hear, feel, measure.
Define inferences.
Interpretation or conclusion made based on cues or observed data.
What must the nurse be careful of when making inferences?
Avoid jumping to conclusion.
Do subjective and objective data agree?
Where does the nursing student organize assessment data?
Summary Assessment Map
What should the nurse avoid when creating the nursing diagnosis?
Avoid MEDICAL diagnosis.
