Care Plan/Concept Map - Unit 4

Question 1

Utilize the nursing process to construct an ___ ___ of __ for a patient based on a critical analysis of patient assessment data.

Answer 1

Individualized plan of care.

Question 2

Nursing Process - def

Answer 2

systematic method of giving humanistic care that focuses on achieving outcomes in a cost-effective manner.

Question 3

Scientific Method - personalized or not personalized?

Answer 3

Not personalized!

Question 4

Intuitive method - direct understanding of the…

Answer 4

situation. Based on background of the situation - knowledge + skill.

Question 5

Care Plans - Organized so nurse can quickly identity nursing actions to be delivered. T/F?

Answer 5

True!

Question 6

5 Steps of the Nursing Process -

Answer 6

Assessment.
Diagnosis.
Planning. 
Implementation. 
Evaluation.

Question 7

Why do we do care plans?

Answer 7

Requirement set forth by National practice standars. (ANA, TJC.) Basis for NCLEX exams, etc.

Question 8

Assessment - the first step in ___ a patient’s health status.

Answer 8

Determining.

Question 9

We don’t need to report significant abnormalities immediately. T/F?

Answer 9

False - we must!

Question 10

Data doesn’t need to be complete or accurate. T/F?

Answer 10

False - it must be!

Question 11

Assessment - what are some of the things we do here?

Answer 11

Gather information (puzzle pieces).

Question 12

What are the 5 activities needed to perform a systematic assessment?

Answer 12

Collect data, verify data, organize data, identify patterns, report & record data.

Question 13

Data collection - begins before you actually see the patient. T/F?

Answer 13

True - like ER notes, chart reviews, etc.

Question 14

What’s important data?

Answer 14

Name, age, gender, advanced directive, lab tests, meds, allergies, support services, emotional state, culture assessment, etc.

Question 15

What is some of the stuff taken from a comprehensive physical assessment?

Answer 15

Vital signs, height/weight, review of systems, standardized risk assessments.

Question 16

Should we cluster data into groups, according to nursing or medical models, like Maslow’s?

Answer 16

Yes!

Question 17

When is the initial assessment done?

Answer 17

Shortly after admission.

Question 18

What is a focused assessment?

Answer 18

When it’s trying to look at one specific problem.

Question 19

Emergency Assessment - what is it?

Answer 19

When there is a crisis.

Question 20

What is a time-lapsed assessment?

Answer 20

Done to compare status to baseline data - could be done in LTC, etc.

Question 21

Diagnoss - what is it?

Answer 21

We take the assessment –> critical analysis –> and then diagnose.

Question 22

Nurses are responsible for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment. T/F?

Answer 22

True!

Question 23

Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved. T/F?

Answer 23

True!

Question 24

Diagnostic reasoning - apply critical thinking to problem identification. T/F?

Answer 24

True!

Question 25

What are some of the fundamental principles of Diagnostic reasoning?

Answer 25

Recognizes diagnosis, keeps an open mind, back up diagnosis with evidence, intuition, independent thinker, know your qualifications and limitations, etc.

Question 26

Nursing Diagnosis - actual problem with evidence. T/F?

Answer 26

True!

Question 27

With a nursing diagnosis, we use medical diagnosis. T/F?

Answer 27

FALSE. It is not a medical diagnosis.

Question 28

We can state 2 separate problems in one diagnosis. T/F?

Answer 28

False!

Question 29

Planning - what do we do here?

Answer 29

Set your priorities of care, what needs done first/last, etc. We have to identify goals and outcomes, etc.

Question 30

Outcomes - need to be time related. T/F?

Answer 30

True!

Question 31

Short term goal - what's the timeframe?

Answer 31

Less than a week.

Question 32

Long term goal - what's the timeframe?

Answer 32

More than a week!

Question 33

Affective goal - what is it?

Answer 33

Change in values, believes, etc. Like smoking!

Question 34

Cognitive Goal - what is it?

Answer 34

Increasing patient knowledge.

Question 35

Psychomotor goal - what is it?

Answer 35

Shows they can do something!

Question 36

Nursing interventions are actions performed by nurse to reach goal or outcome. T/F?

Answer 36

True!

Question 37

Direct Care Intervention - what is it?

Answer 37

Direct action performed to client (like inserting a foley catheter.)

Question 38

Indirect Care Intervention - what is it?

Answer 38

actions performed away from client (looking at lab results.)

Question 39

Physician Intervention - what is it?

Answer 39

An intervention done with an order/by doctor.

Question 40

Collaborative intervention - what is it?

Answer 40

An intervention where everyone is involved.

Question 41

What happens in implementation?

Answer 41

Putting your plan into action, set priorities after report, assess and reassess, perform interventions, etc.

Question 42

Protocols - def

Answer 42

written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation.

Question 43

Standing Orders - document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific conditions. T/F?

Answer 43

True!

Question 44

Implementation Process Involves what 3 things?

Answer 44

Reassessing the client, reviewing and revising the existing care plan, and organizing resources and care delivery (equipment, personnel, environment.)

Question 45

Evaluation - what happens here?

Answer 45

Evaluation of individual plan of care, which includes determining outcome achievement. It measures the client's response to nursing actions and the client's progress toward achieving goals!

Question 46

What is a concept map care plan?

Answer 46

Innovative approach to planning and organizing nursing care. Essentially a diagram of patient problems and interventions! Roots in education and psychology.