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64 Cards in this Set
- Front
- Back
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When is the nursing process used?
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whenever client care is provided....whenever the client and nurse come together
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The nursing process is a method for organizing and _____________ nursing care based on ____________________.
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delivering
problem-solving principles |
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The nursing process is a method used by nurses to expedite diagnosis and treatment of ____________ and _____________ health problems.
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actual and potential health problems
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What are the advantages to the patient when a nurse uses the nursing process?
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improved quality of care & quality of life
continuity of care participation in his/her own care speeds up diagnosis and treatment creates cost effective plan (both in terms of human suffering and monetary expense) has precise documentation |
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The nursing process has tailored interventions for the ____________________ not the ____________.
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individual, not the disease
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Who first introduced the nursing process?
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Lydia Hall in 1955
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The first four steps of the process left out __________ until 1973. Then in 1991, ANA identified _____________as the sixth step.
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diagnosis
outcome identification |
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What are the steps to the nursing process?
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Assessment
Diagnosis Planning Interventions Evaluation ADPIE |
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What are the three important things that are vital for a nursing process to work?
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1. Knowledge and Critical Thinking
2. Skills 3. Caring |
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What are the kinds of assessments?
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initial assessment
& on-going assessment |
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What is another name for initial assessment?
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baseline assessment
data base assessment comprehensive assessment |
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What do initial assessments focus on?
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all body systems, overall picture of health.
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When do you take an initial assessment?
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when you first meet them
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What is an inital assessment used for?
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used to make inital problem list
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What is inital assessment concerned with?
Who can do it? |
client's overall health status
**it has MULTIPLE DATA VARIABLES has to be RN |
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Give an example of a comprehensive assessment tool.
Give an example of a comprehensive assessment. |
med/surg tool
nursing history physician's initial history physical exam |
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An on going assessment is also called a _________________. And it can be further divided into:
A) B) |
Focused Assessment
A) trend assessment B) decision assessment |
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If you are asking questions such as:
What are your symptoms? Are you taking any meds that might be causing this? What type of assessment are you doing? |
focused assessment (aka: ongoing assessment)
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This assessment is done at every shift.
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trend assessment
(focused on specific category, problem or particular area of the body or body system) |
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Why do you do a trend/focused assessment on every shift?
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because you are trying to evaluate the status of existing problems and identify new problems.
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This assessment is to gather a bunch of data.
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Data base assessment
(type of initial assessment) |
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This assessment is done to ID any new problems that may have arisen.
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Focused assessment: trend assessment
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What is a primary data source?
What is a secondary data source? |
patient - primary
textbooks- secondary |
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A panic assessment is an example of this type of assessment.
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decisional assessment
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What are the components of assessment?
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A. Data Collection
B. Data Validation C. Data Organization D. Data Analysis E. Data Reporting/Recording |
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In which ways can you collect data? Give three examples:
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observation
interviewing physical assessment (inspection, palpation, percussion, ausculatate) |
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Subjective and Objective data act as ________.
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Cues - hints or reminders that prompt you to suspect a problem.
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Subjective data is _________.
Objective data is _________. |
Subjective = stated
Objective = observed |
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When you take cues and draw a conclusion, what are you doing?
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infering.....which is only as good as the person inferring.
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What things can help a nurse identify significant cues and make correct inferences?
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1. observational skills
2. nursing knowledge 3. clinical expertise 4. values and beliefs (which could be bad b/c you could be making judgements) |
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What type of data can be accepted as factual?
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data that can be measured accurately...(height, weights, lab study results)
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Why do you need to cluster data?
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to get a clear picture of health status.
Cluster it according to purpose. |
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What type of organizational systems focus on medical models?
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head to toe
body systems |
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How do WE organize information?
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Doenges/Moorhouse
nursing models helps you see nursing problems, medical models helps you see medical problems |
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How do you organize information in order to prioritize?
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according to Maslow's priority of needs
**you can organize or cluster your data a couple of different ways because each way will reveal different data. |
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If you cluster according to body systems, you will reveal.....
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medical problems
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Data analysis can also be called:
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identifying patterns, testing first impressions
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When you analyze correctly, the most important thing you do is.....
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recognize strengths
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When you identify appropriate interventions after correctly analyzing data, what is important about these interventions?
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that they are individualized
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What is the big difference between the nursing model and the medical model when it comes to analyzing data?
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with nursing model, you identify strengths too...in medical model you only focus on problems
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What is the first step to making a diagnosis?
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analyzing
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In our program, analyzing data is part of what step of the nursing process?
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assessment, but it can be part of nursing diagnosis in other programs
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What type of problems should be identified in a nursing diagnosis?
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problems the nurse can legally prescribe definitive interventions independently
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Who is responsible for initiating a plan to treat the problems identified in a nursing diagnosis?
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the nurse is soley accountable
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What words do you avoid when writing a nursing diagnosis?
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As evidenced by
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What is the purpose of a nursing diagnosis?
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provides a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
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What is a second purpose of the nursing diagnosis?
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to clarify the exact nature of the problems and risk factors you need to address to achieve the overall expected outcomes of care.
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What does diagnose and treat (DT) require you to do?
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wait for evidence of problems before beginning treatment.
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What does PPMP approach require you to do?
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with known problems PREDICT the most common and most dangerous complications and take immediate action to PREVENT them and MANAGE THEM
Then you PROMOTE optimum function, independence and well being |
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Actual and potential problems
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diagnosis
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Specific treatments or actions needed to prevent, resolve or manage actual and potential problems
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interventions
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Specific data that is observed in the patient to show that he or she has benefited from care.
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outcome (goal?)
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If you are competent, you have.......
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the knowledge and skills to identify problems and risks and to perform actions safely and efficiently in various situations.
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If you are qualified you have.....
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the authority to perform an action or give a professional opinion.
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What is a definitive intervention?
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the most specific action or tx required to prevent, resolve or manage a health problem.
ex: abx for pneumonia (although a lot of other things would help, without the abx, you won't get very far in the tx) |
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signs
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observable objective data
ex: rashes and fever |
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symptoms
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subjective data
ex: pain and fatigue |
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cues
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signs and symptoms that prompt you to suspect a problem or potential problem
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A definitive diagnosis clearly identifies these two things...
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the problem and the cause
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What is the main focus of the nursing diagnosis?
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the IMPACT of the disease, trauma or life change
ADLs Quality of life issues |
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Which diagnosis has two parts to its statement?
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actual diagnosis
risk diagnosis |
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Which diagnosis only has one part to its statement?
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wellness diagnosis
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What are the only two nursing diagnosis that are equal to medical dx?
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hypothermia
hyperthermia |
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What four things does planning involve?
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1. setting priorities
2. establishing outcomes/goals 3. determining nursing interventions 4. ensuring the plan is adequately recorded |
