Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
69 Cards in this Set
- Front
- Back
What are the 5 steps of the nursing process?
|
assessment
analysis planning implementation evaluation |
|
Define assessment?
|
gather objective and
subjective data verify data |
|
Define analysis?
|
interpret data
collect additional data when necessary identify and communicate nursing diagnoses determine health team's ability to meet client's needs |
|
Define planning?
|
determine and prioritize
goals of care. Include client, significant others, and health team in setting goals develop and modify plan for delivery of client's care |
|
Define implementation?
|
organize and manage the
client's care perform or assist in performance of client's care counsel and teach client, significant others, and health team provide care specifically directed toward achieving goals |
|
Define evaluation?
|
compare actual outcomes with
expected outcomes evaluate compliance with the established regimen or plan record and describe client's response to plan modify plan as indicated, and set priorities |
|
What are the 2 components of the nursing diagnosis?
|
response
etiology |
|
The RESPONSE component of a nursing diagnosis is?
|
includes potential or actual
health response describes measurable outcomes that can be derived cites potential for changes based on nursingn actions example: alteration in comfort, pain |
|
The ETIOLOGY component of a nursing diagnosis is?
|
includes potential or actual
health response addresses independent, inter- dependent, and dependent nursing functions example: related to fractured left ankle |
|
Name 13 NANDA-Approved Nursing Diagnoses?
|
activity/rest
circulation elimination emotional reactions food/fluid hygiene neurologic pain relationship alterations safety sexuality teaching/learning ventilation |
|
Name the Activity/Rest NANDA-Approved Nursing Diagnoses? (7)
|
Activity Intolerance
Activity Intolerance, Potential Disuse Syndrome, Potential for Diversional Activity Deficit Fatigue Physical Mobility, Impaired Sleep Pattern Disturbance |
|
Name the Circulation NANDA-Approved Nursing Diagnoses?
(3) |
Decreased Cardiac Output
Tissue Perfusion, Altered (Specify type: renal, cerebral, cardiopulmonary, GI, peripheral) high risk for peripheral neurovascular dysfunction |
|
Name the Elimination NANDA-Approved Nursing Diagnoses?
(12) |
Constipation
Constipation, Colonic Constipation, Perceived Diarrhea Incontinence, Bowel Incontinence, Functional Incontinence, Reflex Incontinence, Stress Incontinence, Total Incontinence, Urge Urinary Elimination, Altered Urinary Retention |
|
Name the Emotional Reactions NANDA-Approved Nursing Diagnoses?
(22) |
Adjustment, Impaired
Anxiety Body Image Disturbance Individual Coping, Ineffective Defensive Coping Denial, Ineffective Decisional Conflict (Specify) Fear Grieving, Anticipatory Grieving, Dysfunctional Hopelessness Post-Trauma Response Powerlessness Personal Identity Disturbance Rape-Trauma Response Rape-Trauma Syndrome Rape-Trauma Syndrome: Compound Reaction Rape-Trauma Syndrome: Silent Reaction Relocation Stress Syndrome Self-Esteem, Chronic Low Self-Esteem, Situational Low Spiritual Distress |
|
Name the Food/Fluid NANDA-Approved Nursing Diagnoses?
(12) |
Breastfeeding, Ineffective
Interrupted Breastfeeding Fluid Volume, Excess Fluid Volume Deficit, Potential Nutrition Less than Body Requirements, Altered Nutrition More than Body Requirements, Altered Nutrition, Potential for more than Body Requirements, Altered Oral Mucous Membrane, Altered Swallowing, Impaired Ineffective Infant Feeding Pattern |
|
Name the Hygiene NANDA-Approved Nursing Diagnoses?
(2) |
Health-Seeking Behaviors
(Specify) Self-Care Deficit: ---Bathing/Hygiene ---Toileting ---Feeding ---Dressing/Grooming |
|
Name the Neurologic NANDA-Approved Nursing Diagnoses?
(5) |
Communications, Impaired
Verbal Dysreflexia Unilateral Neglect Sensory/Perceptual Alterations (Specify type: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Thought Process, Altered |
|
Name the Pain Nanda-Approved Nursing Diagnoses?
(2) |
Pain
Pain, Chronic |
|
Name the Relationship Alterations NANDA-Approved Nursing Diagnoses? (13)
|
Family Coping: Compromised,
Ineffective Family Coping: Disabling, Ineffective Family Process, Altered Parental Role Conflict Parenting, Altered Role Performance, Altered Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Esteem Disturbance Social Interaction, Impaired Social Isolation Caregiver Role Strain High Risk for Caregiver Role |
|
Name the Safety NANDA-Approved Nursing Diagnoses? (17)
|
Body Temperature, Potential
Altered Health Maintenance, Altered Home Maintenance Management, Impaired Hyperthermia Hypothermia Infection, Potential for Injury, Potential for Poisoning, Potential for Suffocation, Potential for Trauma, Potential for Skin Integrity, Impaired Skin Integrity, Potential Impaired Thermoregulation, Ineffective Tissue Integrity, Impaired Violence, Potential for: Self-directed or directed at others High Risk for Self-Mutilation |
|
Name the Sexuality NANDA-Approved Nursing Diagnoses?
(2) |
Sexual Dysfunction
Sexual Patterns, Altered |
|
Name the Teaching/Learning NANDA-Approved Nursing Diagnoses? (5)
|
Growth and development,
altered Knowledge deficit (specify) Noncompliance (specify) Ineffective management of therapeutic regimen (individuals) Therapeutic regimen: (community, families): ineffective management |
|
Name the Ventilation NANDA-Approved Nursing Diagnoses?
(6) |
Airway clearance, ineffective
Aspiration, potential for Breathing pattern, ineffective Gas exchange Dysfunctional ventilatory weaning response Inability to sustain spontaneous ventilation |
|
Name Maslow's Hierarchy of Needs in order. (6)
|
Physiologic
Safety Love and Belonging Esteem and Recognition Self-Actualization Aesthetic |
|
What is the definition of Maslow's Physiologic?
|
Biologic needs for food, shelter, water, sleep, oxygen, sexual expression
|
|
What is the definition of Maslow's Safety?
|
Avoiding harm; attaining security, order, and physical safety
|
|
What is the definition of Maslow's Love and Belonging?
|
Giving and receiving affection; companionship; and identification with a group
|
|
What is the definition of Maslow's Esteem and Recognition?
|
Self-esteem and respect of others; success in work; prestige
|
|
What is the definition of Maslow's Self-Actualization?
|
Fulfillment of unique potential
|
|
What is the definition of Maslow's Aesthetic?
|
Search for beauty and spiritual goals
|
|
The priority biologic need is?
|
breathing i.e. open airway
|
|
Ensuring that the client's environment is 1____ is a priority, e.g., teaching an older client to remove throw rugs which pose a safety hazard when ambulating would have a greater priority than teaching how to use a walker - FIRST priority is 2____, then 3____ skills.
|
1 SAFE
2 safety 3 coping |
|
Which action has a higher priority...assisting the client in becoming a part of a support group...or assisting him/her in developing self-esteem?
|
sense of belonging comes first, and such a sense might help in developing self-esteem
|
|
What provides the laws that control the practice of nursing in each state?
|
Nurse Practice Acts
|
|
A tort is an act involving injury or damage to another (except 1_____ of contract) resulting in 2_____ liability (i.e. the victim can sue) instead of 3_____ liability (see crime).
|
1 breech
2 civil 3 criminal |
|
Two unintentional torts are?
|
negligence
malpractice |
|
Negligence is a form of ______ tort whereby performing an act that a reasonable and prudent person would not do. Measure of negligence is "_____" (i.e. would a reasonable and prudent nurse act in the same manner under the same circumstance?)
|
unintentional
reasonableness |
|
Malpractice is a form of ______ tort whereby there is negligence of professional _____, e.g., professional misconduct, or unreasonable lack of skill in carrying out professional duties.
|
unintentional
misconduct |
|
What four elements are necessary to prove negligence/malpractice and if any element is missing, it cannot be proved?
|
duty
breach of duty injury/damages causation |
|
What is DUTY? (one of the four elements that proves negligence/malpractice and cannot be missing)
|
The obligation to use due care (what a reasonable, prudent nurse would do)
Failure to care for and/or to protect others against unreasonable risk. |
|
DUTY (one of four elements of negligence/malpractice) must _______ foreseeable risks.
Example: If a floor has water on it, the nurse is responsible for anticipating the risk to the client of falling. |
ANTICIPATE
|
|
What is BREACH OF DUTY? (one of the four elements that proves negligence/malpractice and cannot be missing)
|
Failure to perform according to the established standard of conduct in providing nursing care.
|
|
What is INJURY/DAMAGES? (one of the four elements that proves negligence/malpractice and cannot be missing)
|
Failure to meet standard of care, which causes actual injury or damage to the client, either physical or mental.
|
|
What is CAUSATION? (one of the four elements that proves negligence/malpractice and cannot be missing)
|
A connection exists between conduct and the resulting injury referred to as "proximate cause" or "remoteness of damage"
|
|
Hospital policies provide a guide for nursing 1_____.
They are NOT 2____, but courts generally rule against nurses who have violated the employer's policies. Hospitals can be liable for poorly formulated or poorly implemented policies. |
1 actions
2 laws |
|
What alerts administration to possible liability claims and the need for investigation; they do NOT _____ against legal action being taken for negligence or malpractice.
|
Incident report
protect |
|
Burning a client with a hot water bottle or heating pad is an example of?
|
negligence/malpractice
|
|
Two forms of intentional tort are?
|
assault
battery |
|
What is the term used for mental or physical threat, e.g., forcing (without touching) a client to take a medication or treatment?
|
assault
|
|
What is the term used when touching, with or without the intent to do harm, e.g., hitting or striking a client. If a mentally competent adult is forced to have a treatment and has refused, this occurs?
|
battery
|
|
Leaving sponges or instruments in a client in surgery is an example of?
|
negligence/malpractice
|
|
What is the term for encroachment or trespassing on another's body and/or personality?
|
invasion of privacy
|
|
Confinement without authorization?
|
false imprisonment
|
|
Exposure or discussion of the client's case. After death, the client has a right to be unobserved, excluded from unwarranted operations, and protected from unauthorized touching of the body?
|
exposure of a person
|
|
Performing incompetent assessments is an example of?
|
negligence/malpractice
|
|
Divulgence of privileged information or communication, e.g., from charts, conversations, or observations?
|
defamation
|
|
Failing to heed warning signs of shock or impending MI is an example of?
|
negligence/malpractice
|
|
Willful and purposeful misrepresentation that could cause, or has caused, loss or harm to a person or property?
|
fraud
|
|
Ignoring signs and symptoms of bleeding is an example of?
|
negligence/malpractice
|
|
Presenting false credentials for the purpose of entering nursing school, obtaining a license, or obtaining employment is termed?
|
fraud
|
|
A legal term meaning the accused is not criminally responsible for the unlawful act committed due to mental illness?
|
insanity
|
|
Forgetting to give a medication or giving the wrong medication is an example of?
|
negligence/malpractice
|
|
An act contrary to a criminal statute. Wrongs punishable by the state, committed against the state, with intent usually present.
|
crime
|
|
Legal hearing that is held to determine a person's capability to make responsible decisions about self, dependent, or property?
|
competency hearing
|
|
Persons declared incompetent have the legal status of a minor, i.e., they cannot? (5)
|
vote
make contracts or wills drive a car sue or be sued hold a professional license |
|
If a person is incompetent, a _____ is appointed. Declaring a person incompetent can be initiated by the ____ or family.
|
guardian
state |
|
An admission whereby any adult may apply for another. However, medical or judicial approval is required to detain anyone beyond 24 hours.
|
emergency admmission
|
|
Emergency admissions allow persons held against their will to file a ____ _____ to try and get the court to hear their case and release them.
|
habeas corpus
|
|
With emergency admissions, the court determines the ____ and alleged unlawful restraint of a person.
|
sanity
|