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220 Exam 2 > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

nursing process
human response to __________ or ___________ problem

A

actual, potential

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2
Q

nursing process

A

holistic
scientific
EBP
individualized
analyze information

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3
Q

critical thinking
mental process of

A

recognizing, analyzing, applying and evaluating information to reach a conclusion

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4
Q

clinical thinking

A

use critical thinking in a clinical setting to make nursing care decisions based on EBP

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5
Q

standardized language

A

always using the same wording

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6
Q

do nurses treat the medical diagnosis

A

no

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7
Q

benefits of standardized nursing language

A

defines nursing contribution and impact in healthcare
defines what nurses do
gives nurses more EB outcomes and interventions
easily integrated into EMR
standardizes knowledge for nursing curriculum
promotes nursing research

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8
Q

ADPIE

A

assessment
diagnosis
planning
implementation
evaulation

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9
Q

what step comes first

A

assessment

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10
Q

what comes after assessment

A

diagnosis

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11
Q

what are the 2 parts of diagnosis

A

actual- 3 part
risk - 2 part

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12
Q

what comes after diagnosis

A

planning

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13
Q

what are the two parts of planning

A

patient outcomes
nursing interventions

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14
Q

what comes after planning

A

implement

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15
Q

what comes after implementation

A

evaulation

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16
Q

what does evaluation lead back to

A

patient outcomes

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17
Q

what are the types of assessment

A

inital
- admission
- shift
focused
time lapsed

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18
Q

what is an admission assessment

A

completed within 8 hours of admission (mandated by joint commission)
baseline for hospitalization

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19
Q

what is a shift assessment

A

what you do at the beginning of shift
baseline for day

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20
Q

what is a focused assessment

A

only focus on one system

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21
Q

a patient returns a few days after an appointment for asthma unplanned
what assessment

A

focused

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22
Q

what is a time lapsed assessment

A

treatment for specific time
purposely come back after certain time

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23
Q

a patient returns for a follow up appointment 2 months after a previous appointment for COPD
what assessment

A

time lapsed

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24
Q

what is the best source for data

A

patient

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25
Q

if the patient is not available what is the next best source for data

A

family and significant others

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26
Q

if the patient and family/significant others are not available what is the next best source for data

A

patient record

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27
Q

if the patient, family/significant others, records, are not available what is the next best source for data

A

other healthcare professionals

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28
Q

subjective

A

what the patient says

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29
Q

objective

A

measurable and observable

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30
Q

nursing diagnosis

A

clinical judgment about an individuals responses to actual or potential health problems

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31
Q

nursing diagnosis provides the basis for selection of __________ _______ and __________ ______________ to achieve the set outcomes

A

patient outcomes, nursing interventions

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32
Q

steps in diagnosis process

A
  • create a list of suspected problems
  • name actual and problems/diagnoses and clarify what is causing or contrubituing to them
  • determine risk factors that must be managed for a risk DX
  • confirm defining characteristics for an actual DX
  • prioritize nursing diagnoses
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33
Q

2 nursing diagnosis in fundamentals class

A

problem focused diagnosis
risk diagnosis

34
Q

problem focused diagnosis

A

actual problem

35
Q

risk diagnosis

A

risk of problem developing

36
Q

what is an etiology

A

cause of the problem

37
Q

what are the only 2 nursing diagnosis that have etiologies

A

problem (actual) and syndromes

38
Q

when would there be a medical diagnosis in a nursing diagnosis

A

secondary

39
Q

what comes first in a actual nursing diagnosis

A

problem

40
Q

what comes after problem

A

r/t etiology

41
Q

what comes after etiology

A

defining characterisitcs

42
Q

problem drives

A

outcomes

43
Q

etiology drives

A

nursing intervetnions

44
Q

what is included in a actual diagnosis

A

problem
R/T
etiology
AEB
defining characterisitcs

45
Q

what is included in a at risk diganosis

A

problem statment
AED
risk factor

46
Q

are there defining characteristics in a at risk diagnosis

A

no because it doesn’t exist yet

47
Q

what are the diagnosis that have risk factors

A

risk diagnosis

48
Q

nursing diagnosis is in response to the

A

medical diagnosis

49
Q

what might be a nursing diagnosis for
pneumonia

A

ineffective airway clearance

50
Q

what might be a nursing diagnosis for
amputation

A

disturbed body image

51
Q

what might be a nursing diagnosis for
type 2 diabetes

A

risk for unstable blood glucose

52
Q

5 levels to Maslow

A

physiologic
safety and security
love and belonging
self esteem
self actualization

53
Q

what belongs in physiologic needs

A

oxygen
food
elmination
temp control
sex
movement
rest
comfort

54
Q

what belongs in safety and security

A

safety from threat, protection, continuity, stability, lack of danger

55
Q

what belongs in love and belonging

A

affiliation, affection, intamacy, support, reasurance

56
Q

what belongs in self esteem

A

sense of worth, self respect, independence, dignity, privacy, self reliance

57
Q

what belongs in self actulization

A

recognition and realization of ones potential, growth, health, and autonomy

58
Q

affection belongs in what category

A

love and belonging

59
Q

sense of self worth belongs in what category

A

self esteem

60
Q

lack of danger belongs in what category

A

safety and security

61
Q

growth belongs in what category

A

self actualization

62
Q

comfort belongs in what category

A

physiologic

63
Q

support belongs in what category

A

love and beloning

64
Q

privacy belongs in what category

A

self esteem

65
Q

autonomy belongs in what category

A

self actualization

66
Q

food belongs in what category

A

physiologic

67
Q

benefits of nursing diagnosis

A

individualizing care
defining domain of nursing
reimbursement for nursing services

68
Q

problem drives

A

patient outcomes

69
Q

etiology drives

A

nursing interventions

70
Q

nursing care plan allows

A

individualize care
set priorities
facilitate communication
promote continuity
evaluate patent response
create a record

71
Q

4 types of outcomes

A

cognitive
psychomotor
affective
physiologic

72
Q

cognitive outcome

A

increase patient knowlegde
teaching

73
Q

psychomotor outcome

A

patients achèvement of new skills
demonstrate what was teached

74
Q

affective outcome

A

changes in patients values, beliefs, and attitudes
change habits

75
Q

physiologic outcomes

A

physical change in patient

76
Q

what can we do with a care plan after evaulation

A

terminate, continue, modify

77
Q

terminate

A

when each expected outcome is achieved

78
Q

modify

A

when there are difficulties

79
Q

continue

A

more time is needed to achieve the outcomes

80
Q

NEVER EVENTS

A

pressure injury stages 3-4
falls
trauma
surgical site infection
vascular catheter associated infection
CAUTI
administration of incompatible blood
air embolism
foreigin object in body after surgery

81
Q

foley care

A

good peri care
clean 6 in down cath
secure to leg
green clip on bedding
no dependent loop
bag off floor

82
Q

ALWAYS EVENTS

A

including patient identifications by more than one source
mandatory read backs
disclosure of adverse outcomes
medication error reduction strategies
tracking of critical imaging, lab and pathology results
critical information avaibale at handoffs or transitions in care

220 Exam 2 (13 decks)

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