Nursing Process Flashcards

1
Q

What are the purposes of the diagnosing step in the Nursing Process?

A
  1. Identify how an individual, group, or community responds to actual or potential health and life processes
  2. Identify factors that contribute to, or cause, health problems (etiologies)
  3. Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems
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2
Q

Patient Problems Statements focuse on what?

A

Problem statements focus on unhealthy responses to health and illness; may change from day to day as the patient’s responses change

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3
Q

Medical Diagnosis identifies what?

A

Identifies diseases

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4
Q

Medical Diagnosis describes what?

A

describe problems for which the physician or advanced practice nurses directs the primary treatment;

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5
Q

Does the medical diagnosis change?

A

remains the same for as long as the disease is present

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6
Q

Diagnostic Reasoning, Clinical Reasoning, and Clinical Judgment- how to?

A

Be familiar with lists of actual and potential problems and needs; read professional literature and keep reference guides handy

Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide

Respect your clinical intuition, but before writing a problem statement without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition

Recognize personal biases and keep an open mind

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7
Q

Steps of Data Interpretation and Analysis

A

Recognizing significant data: Comparing data to standards

Recognizing patterns or clusters

Identifying strengths and current or potential problems

Identifying potential complications

Reaching conclusions

Partnering with the patient and family

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8
Q

Types of Nursing Diagnoses

A

Problem-focused
Risk
Health promotion

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9
Q

Formulation of Nursing Diagnoses

A

Problem

Etiology

Signs and Symptoms

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10
Q

What is ‘Problem’ in the Formulation of Nursing Diagnoses?

A

Identifies what is unhealthy about patients

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11
Q

What is ‘Etiology’ in the Formulation of Nursing Diagnoses?

A

Identifies factors maintaining the unhealthy state

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12
Q

Goal of Outcome Identification and Planning Step

A

Establish priorities

Identify and write expected patient outcomes

Select evidence-based nursing interventions

Communicate the nursing plan of care

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13
Q

A Formal Care Plan Allows the Nurse to:

A

Individualize care that maximizes outcome achievement

Set priorities

Facilitate communication among nursing personnel and colleagues

Promote continuity of high-quality, cost-effective care

Coordinate care

Evaluate patient response to nursing care

Create a record used for evaluation, research, reimbursement, and legal reasons

Promote nurse’s professional development

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14
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What should you be familiar with?

A

Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan

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15
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What is the goal?

A

Remember that the goal of thoughtful, patient-centered practice is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification

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16
Q

Outcome Identification, Planning, and Clinical Reasoning #1: What is the ‘big picture’ focus?

A

Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?

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17
Q

Outcome Identification, Planning, and Clinical Reasoning #2

A

Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice

Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan

Recognize your personal biases and keep an open mind

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18
Q

Three Elements of Comprehensive Planning

A
  1. Initial
  2. Ongoing
  3. Discharge
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19
Q

Initial Planning- who is it developed by?

A

Developed by the nurse who performs the nursing history and physical assessment

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20
Q

Initial Planning- what does it address?

A

Addresses each problem listed in the prioritized problem list

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21
Q

Initial Planning -identifies what?

A

Identifies appropriate patient goals and related nursing care

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22
Q

Ongoing planning- who is it carried out by?

A

Carried out by any nurse who interacts with patient

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23
Q

Ongoing planning- what does it do to the plan?

A

Keeps the plan up to date, manages risk factors, promotes function

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24
Q

Ongoing planning- what does it have to do with problem statements?

A

States problem statements more clearly

Develops new problem statements

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25
Q

Ongoing planning- what does it do to the outcomes and nursing interventions?

A

Makes outcomes more realistic and develops new outcomes as needed

Identifies nursing interventions to accomplish patient goals

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26
Q

Discharge Planning- who is it carried out by?

A

Carried out by the nurse who worked most closely with the patient

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27
Q

Discharge Planning- when does it begin?

A

Begins when the patient is admitted for treatment

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28
Q

Discharge planning: what does it use?

A

Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently

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29
Q

What is the first part of the nursing diagnosis? (problem statement)

A

Identifies the unhealthy response

Indicates what should change

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30
Q

What does the first part of the nursing diagnosis LEAD to?

A

Suggests patient goals/outcomes (expectations for change)

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31
Q

What is the second part of the nursing diagnosis? (etiology)

A

Identifies factors causing or contributing to the undesirable response and preventing desired change.

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32
Q

What is the second part of the nursing diagnosis? (etiology) lead to?

A

Suggests nursing interventions

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33
Q

What are the priorities that need to be established?

A

Maslow’s hierarchy of human needs

Patient preference

Anticipation of future problems

Critical thinking/clinical reasoning and judgement

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34
Q

Maslow’s hierarchy of human needs

A

Physiologic needs

Safety needs

Love and belonging needs

Self-esteem needs

Self-actualization needs

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35
Q

Clinical Reasoning and Establishing Priorities #1

A

What problems need immediate attention and which ones can wait?

Which problems are the responsibility of the nurse and which need to be referred to someone else?

Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)?

Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?

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36
Q

Clinical Reasoning and Establishing Priorities #2

A

Have changes in the patient’s health status influenced the priority of nursing diagnoses/problems?

Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses/problems that can be realistically addressed?

Are there relationships among diagnoses/problems that require that one be worked on before another can be resolved?

Can several patient problems be dealt with together?

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37
Q

Categories of Outcomes

A

Cognitive:

Psychomotor:

Affective:

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38
Q

Categories of Outcomes: Cognitive

A

describes increases in patient knowledge or intellectual behaviors

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39
Q

Categories of Outcomes: Psychomotor

A

describes patient’s achievement of new skills

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40
Q

Categories of Outcomes: Affective

A

describes changes in patient values, beliefs, and attitudes

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41
Q

Clinical outcomes

A

Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved

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42
Q

Functional outcomes

A

Functional outcomes describe the person’s ability to function in relation to the desired usual activities

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43
Q

Quality-of-life outcomes

A

Quality-of-life outcomes focus on key factors that affect someone’s ability to enjoy life and achieve personal goals

44
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care

A

Safe:
Effective:
Patient-centered:
Timely:
Efficient:
Equitable:

45
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: SAFE

A

Safe: avoiding injury

46
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFECTIVE

A

Effective: avoiding overuse and underuse

47
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: Patient-centered

A

Patient-centered: responding to patient preferences, needs, and values

48
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: TIMELY

A

Timely: reducing waits and delays

49
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EFFICIENT

A

Efficient: avoiding waste

50
Q

IOM’s Six Aims to Be Met by Health Care Systems Regarding Quality of Care: EQUITABLE

A

Equitable: providing care that does not vary in quality to all recipients

51
Q

Joint Commission National Patient Safety Goals (7 Goals)

A

Identify patients correctly

Improve staff communication

Use medicines safely

Use alarms safely

Prevent infection

Identify patient safety risks

Prevent mistakes in surgery

52
Q

Types of Nursing Interventions

A

Nurse-initiated:
Physician-initiated:
Collaborative:

53
Q

Types of Nursing Interventions: Nurse Initiated

A

Nurse-initiated: autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes

54
Q

Types of Nursing Interventions: Physician initiated

A

Physician-initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor’s orders

55
Q

Types of Nursing Interventions: Collaborative

A

Collaborative: treatments initiated by other providers and carried out by a nurse

56
Q

Structured Care Methodologies

A

Procedure:

Standard of care:
Algorithm:

Clinical practice guideline:

57
Q

Structured Care Methodologies: Procedure

A

Procedure: set of how-to action steps

58
Q

Structured Care Methodologies: Standard of care:

A

Standard of care: description of acceptable level of patient care

59
Q

Structured Care Methodologies: Algorithm:

A

Algorithm: set of steps used to make a decision

60
Q

Structured Care Methodologies: Clinical practice guideline

A

Clinical practice guideline: statement outlining appropriate practice for clinical condition or procedure

61
Q

Formats of Care Plans

A

Computerized care plans

Concept map care plans

Change of shift reports

Multidisciplinary (collaborative) care plans

Student care plans

62
Q

Purposes of Implementation

A

Help the patient achieve valued health outcomes

Promote health

Prevent disease and illness

Restore health

Facilitate coping with altered functioning

63
Q

Focus of Nursing Implementation

A

Scope of Practice: Who, what, where, when, and why

Nursing interventions taxonomy structure

Care coordination and continuity

64
Q

Types of Nursing Interventions

A

Those providing direct and indirect care

Independent and collaborative interventions

Protocols and standing orders

Care bundles

65
Q

Implementing Guidelines #1

A

Act in partnership with the patient/family

Before implementing, reassess the patient to determine whether the action is still needed

Approach the patient competently

Approach the patient caringly

Modify nursing interventions according to specific criteria.

66
Q

You modify nursing interventions according to what?

A
  1. Developmental and psychosocial background
  2. ability and willingness to participate in the care plan
  3. responses to previous nursing measures and progress toward goal/outcome achievement
67
Q

Implementing the Plan of Care #1

A

Determine the patient’s new or continuing need for assistance

Promote self-care

Assist the patient to achieve valued health outcomes

Reassess the patient and review the plan of care

Use patient boards or whiteboards

Plan ahead and organize resources

Clarify prerequisite nursing competencies

68
Q

Implementing the Plan of Care #2

A

Anticipate unexpected outcomes and solutions

Ensure quality and patient safety

Promote self-care: teaching, counseling, and advocacy

Assist patients to meet health outcomes

69
Q

Reassessing the Patient and Reviewing the Care Plan

A

Be sure that each nursing intervention is supported by a sound scientific rationale, as demanded by an evidence-based practice

Be sure that each nursing intervention is consistent with professional standards of care and consistent with the protocols, policies, and procedures of the institution or agency

Be sure that the nursing actions are safe for this particular patient and individualized to the patient’s preferences

Clarify any questionable orders

70
Q

Variables Influencing Outcome Achievement

A

Patient variables

Nurse variables

71
Q

Variables Influencing Outcome Achievement: Patient variables

A

Developmental stage

Psychosocial background and culture

72
Q

Variables Influencing Outcome Achievement: Nurse variables

A

Resources

Scope of practice and current standards of care

Research findings

Ethical and legal guides to practice

73
Q

Common Reasons for Noncompliance

A

Lack of family support

Lack of understanding about the benefits

Low value attached to outcomes

Adverse physical or emotional effects of treatment

Inability to afford treatment

Limited access to treatment

74
Q

Five Rights of Delegation

A
  1. Right Task
  2. Right Circumstances
  3. Right person
  4. Right directions and communication
  5. Right supervision and evaluation
75
Q

During evaluation what does the Nurse and patient do together?

A

Nurse and patient together measure how well the patient has achieved the outcomes specified in the care plan

76
Q

During evaluation, what does the nurse identify?

A

The nurse identifies factors that contribute to the patient’s ability to achieve expected outcomes and, when necessary, modifies the plan of care

77
Q

What is the purpose of evaluation?

A

The purpose of evaluation is to allow the patient’s achievement of expected outcomes to direct future nurse-patient interactions

78
Q

Five Classic Elements of Evaluation:

A
  1. Identifying evaluative criteria and standards
  2. Collecting data to determine whether criteria and standards are met
  3. Interpreting and summarizing findings
  4. Documenting judgment
  5. Terminating, continuing, or modifying the plan
79
Q

Evaluating outcome: what do you evaluate?

A

Cognitive:
Psychomotor:
Affective:
Physiologic:

80
Q

Evaluating outcome: what do you evaluate?Cognitive

A

Cognitive: asking patient to repeat information or apply new knowledge

81
Q

Evaluating outcome: what do you evaluate? Psychomotor

A

Psychomotor: asking patient to demonstrate new skill

82
Q

Evaluating outcome: what do you evaluate? Affective

A

Affective: observing patient behavior and conversation

83
Q

Evaluating outcome: what do you evaluate? Physiologic

A

Physiologic: using physical assessment skill to collect and compare data

84
Q

Variables Affecting Outcome Achievement

A

Patient

Nurse

Health care system

85
Q

Variables Affecting Outcome Achievement: Patient example

A

For example, a patient gives up and refuses treatment

86
Q

Variables Affecting Outcome Achievement: Nurse example

A

For example, a nurse is suffering from burnout

87
Q

Variables Affecting Outcome Achievement: Health care system

A

For example, inadequate staffing

88
Q

Actions Based on Patient Response to Care Plan

A

Delete or modify the diagnosis/problem

Make the outcome statement more realistic

Ime criteria in outcome statement

Change nursing interventions

89
Q

Seven Crucial Conversations in Health Care

A

Broken rules

Mistakes

Lack of support

Incompetence

Poor teamwork

Disrespect

Micromanagement

90
Q

Documentation

A

Written or electronic legal record of all pertinent interactions with the patient

Includes data related to assessing, diagnosing, planning, implementing, and evaluating

Facilitates quality, evidence-based patient care

Serves as financial and legal record

Helps in clinical research

Supports decision analysis

91
Q

Elements of Documentation

A

Content
Timing
Format
Accountability
Confidentiality

92
Q

What Is Confidential?

A

All information about patients written on paper, spoken aloud, saved on computer

93
Q

What Is Confidential? Examples

A

Name, address, phone, fax, social security number

Reason the person is sick

Treatments patient receives

Information about past health conditions

94
Q

Potential Breaches in Patient Confidentiality

A

Displaying information on a public screen

Sending confidential e-mail messages via public networks

Sharing printers among units with differing functions

Discarding copies of patient information in trash cans

Holding conversations that can be overheard

Faxing confidential information to unauthorized persons

Sending confidential messages overheard on pagers

95
Q

Patient Rights

A

Patients have the right to:

See and copy their health record

Update their health record

Get a list of disclosures

Request a restriction on certain uses or disclosures

Choose how to receive health information

96
Q

Policy for Receiving Verbal Orders

A

Must be given directly by the physician or nurse practitioner to a registered professional nurse or registered professional pharmacist

Record the orders in patient’s medical record with the initials VO

Read back the order to verify accuracy

Date and note the time orders were issued

Record verbal order and name of the physician or NP issuing the order, followed by nurse’s name and initials

Should be limited to urgent situations

97
Q

Methods of Documentation

A

Computerized documentation/Electronic health records (EHRs)

Source-Oriented Records

Problem-Oriented Medical Records

PIE Charting: Problem, Intervention, Evaluation

Focus Charting

Charting by Exception

98
Q

Source-Oriented Records include

A

Progress notes; narrative notes

99
Q

Problem-Oriented Medical Records include

A

SOAP notes

100
Q

Formats for Nursing Documentation

A

Initial nursing assessment

Care plan; patient care summary

Critical collaborative pathways

Progress notes

Flow sheets and graphic records

Medication
administration record

Acuity record

Discharge and transfer summary

Home health care documentation

Long-Term care documentation

101
Q

Reporting Care or Requesting Action

A

Change of Shift/Handoff Report

ISBARR

Telephone/Telemedicine Report

Transfer and Discharge Reports

Reports to Family

Members or Significant Others

Incident/Variance Reports

102
Q

Hand-off Communication/ISBARR

A

Identity/Introduction

Situation

Background

Assessment

Recommendation

Read back of orders/response

103
Q

Change of Shift/Hand-off Reports

A

Basic identifying information about each patient: name, room number, bed designation, diagnosis, and attending and consulting physicians

Current appraisal of each patient’s health status

Current orders (especially any newly changed orders)

Abnormal occurrences during your shift

Any unfilled orders that need to be continued onto the next shift

Patient/family questions, concerns, needs

Reports on transfers/discharges

104
Q

Telephone/Telemedicine Reports

A

Identify yourself and the patient, and state your relationship to the patient

Report concisely and accurately the change in the patient’s condition that is of concern and what has already been done in response to this
condition

Report the patient’s current vital signs and clinical manifestations

Have the patient’s record at hand to make knowledgeable responses to any physician’s inquiries

Concisely record time and date of the call, what was communicated, and physician’s response

105
Q

Conferring about Care

A

Consultations and referrals

Nursing and interdisciplinary team care conferences

Nursing care rounds

Purposeful rounding

106
Q

Eight Behaviors of Purposeful Rounding

A

Use Opening Key Words (C-I-CARE) with PRESENCE

Accomplish scheduled tasks

Address four Ps

Address additional personal needs, questions

Conduct environmental assessment

Ask “Is there anything else I can do for you? I have time.”

Tell the patient when you will be back

Document the round