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NURS 175 - Nursing Practice Foundations > Lesson 3 - The Nursing Process > Flashcards

Lesson 3 - The Nursing Process Flashcards

1
Q

The Nursing Process

A

-ongoing (cyclical) process used with every patient interaction

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2
Q

Nursing Process Characteristics

A

-client-centered
-focuses on problem solving and decision making
-collaborative
-uses critical thinking

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3
Q

Purpose of the Nursing Process

A

-gather data (ie. by interview, chart, environment)
-cluster data (ie. by body system or hierarchy of needs)
-engage in critical thinking and clinical reasoning
-make decisions
-plan and evaluate care

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4
Q

Step 1: Assessment

A

-collect, organize, validate, document data
-results in comprehensive understanding of patient situation
-holistic: past and present health status

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5
Q

Initial Assessment

A

-explores presenting problem and contributing factors
-physical assessment
-health history
-psychosocial assessments

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6
Q

Focused Assessment

A

-gathers specific details about presenting concern
-confirms or rules out abnormalities

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7
Q

Time-lapsed Assessment

A

-reevaluate status
-has condition improved, worsened, or remained?

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8
Q

Emergency Assessment

A

-ensure ABCs (airway, breathing, circulation)
-identify primary cause of problem

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9
Q

Expected Findings Before Nursing School

A

-world view
-previous experiences
-culture, religion, family, friends
-K-12 knowledge

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10
Q

Expected Findings During/After Nursing School

A

-understanding other perspectives
-school and clinical experiences
-cultural humility
-interpersonal relationship knowledge
-nursing knowledge

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11
Q

Step 2: Nursing Diagnosis

A

-analyze data (significant vs. insignificant)
-identify problems, risks, strengths
-formulate diagnostic statements
-expected vs. unexpected findings

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12
Q

Step 3: Planning

A

-prioritize (Mazlows Hierarchy of Needs)
-goals/desired outcomes
-identify nursing interventions

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13
Q

Step 4: Implementation

A

-reassess patient
-determine need for assistance
-implement nursing interventions
-ensure interventions are in scope of practice
-document what you have done
-maintain safety
-teaching

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14
Q

Step 5: Evaluation

A

-collect outcome related data
-draw conclusions
-continue, modify, or end care plan

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15
Q

Interprofessional Teams (data sources)

A

-physicians (+ their notes)
-dietician
-PT
-OT
-spiritual caregiver
-social worker

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16
Q

Medical Record/Chart

A

-holds various info in the form of a patient “file”
-nursing documentation, medical records, progress notes, test/lab results, interdisciplinary team notes

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17
Q

Other sources of data

A

-books
-physical assessment
-patient and family

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18
Q

Health Interview

A

-opportunity for nurse and patient to exchange information and form a therapeutic relationship
-doesn’t always have to be formal
-trust, respect, genuine

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19
Q

Health Interview: Verbal Communication

A

-open + closed ended questions
-leading + neutral questions
-paraphrasing
-clarification

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20
Q

Health Interview: Nonverbal Communication

A

-facial expressions
-gestures
-posture
-attentiveness

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21
Q

Social Determinants of Health

A

-provide important context to life situations, health, relationships, outcomes, risks

22
Q

Sight (Assessment Tool)

A

-skin tone/bruises
-abnormal movements
-consciousness level
-response to touch

23
Q

Smell (Assessment Tool)

A

-unique smells

24
Q

Touch (Assessment Tool)

A

-skin temp
-fluid volume (edema)

25
Q

Sound (Assessment Tool)

A

-verbal
-body processes

26
Q

Primary Data Sources

A

-patient

27
Q

Secondary Data Sources

A

-family & friends
-environment
-records
-interprofessional team
-literature

28
Q

Subjective Data

A

-based on feelings, opinions

29
Q

Objective Data

A

-factual, measurable
-not based on opinion

30
Q

Inference

A

-conclusion reached from evidence and reasoning
-confirm with patient
-look at other data to validate

31
Q

Gordon’s Functional Health Patterns

A

-used to gather patient info and sort the data into categories
-ie. elimination, nutrition-metabolic, sleep-rest, role-relationship, etc.

32
Q

Maslow’s Hierarchy of Needs

A

-from bottom (physiological needs) to top (self-actualization)

33
Q

Physiological Needs (bottom)

A

-breathing, food, water, excretion

34
Q

Safety

A

-security of body, employment, health, property

35
Q

Love/belonging

A

-family and friends
-intimacy

36
Q

Esteem

A

-confidence, respect, achievement

37
Q

Self-actualization (top)

A

-morality
-creativity
-lack of prejudice

38
Q

Nursing Diagnosis

A

-focus on human response to actual or potential health problems/quality of life
-within scope of practice

39
Q

Medical Diagnosis

A

-focus on illness/medical problem

40
Q

NANDA-I

A

-North American Nursing Diagnosis Association - International
-13 categories
-ie. nutrition, activity and rest, comfort, etc.
-use nursing diagnosis handbook

41
Q

Steps to formulate Nursing Diagnosis

A
  1. Choose a NANDA-I label (actual/risk/wellness/syndrome)
  2. determine etiology (likely cause) of problem
  3. List manifestations (signs and symptoms) - not for RISK!
42
Q

Initial Planning

A

-based on admission assessment
-directs patient care

43
Q

Ongoing Planning

A

-continually changing plans based on response to care
-based on assessment and evaluation

44
Q

Discharge Planning

A

-anticipate and plan for care needs when patient moves home or to another facility

45
Q

Goals/Outcomes

A

-broad statements
-relate to nursing diagnosis

46
Q

SMART Goals

A

-specific
-measurable
-achievable
-relevant
-timely

47
Q

Independent Nursing Intervention

A

-nurse can accomplish without order from doc or np

48
Q

Dependent Nursing Intervention

A

-based on doc orders

49
Q

Collaborative Nursing Intervention

A

-nurse + another professional work together

50
Q

Direct Care

A

-involves working directly with the patient

51
Q

Indirect Care

A

-communicating with other HCPs about care
-delegate, supervise, evaluate others work
-plan and document care

52
Q
A

NURS 175 - Nursing Practice Foundations (11 decks)

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