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Foundations Exam 2 > CH. 11-15 > Flashcards

CH. 11-15 Flashcards

1
Q

What is the nursing process?

A

An orderly and systematic problem-solving approach to patient-centered care.

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2
Q

Why do we perform nursing assessments?

A
  • Establish baseline
  • determine pt. normal function
  • determine pt. risk of dysfunction
  • determine presence or absence of dysfunction
  • determine pt. strengths
  • provide data for diagnosis phase
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3
Q

What are the four types of assessments?

A
  • Admission
  • Focus
  • Time-lapse
  • Emergency
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4
Q

Explain an admission assessment:

A

Determine reference baseline.

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5
Q

Explain a focus assessment:

A

Determining status of a specific problem.

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6
Q

Explain a time-lapse assessment:

A

Determining change from previous findings.

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7
Q

Explain an emergency assessment:

A

Determining presence of life-threatening conditions.

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8
Q

Explain observation:

A

Use of all senses to collect data.

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9
Q

Explain interviewing:

A

Collects subjective data for nursing history.

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10
Q

What are the phases of interviewing?

A
  • Preparatory
  • Introductory
  • Maintenance
  • Concluding
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11
Q

What are physical examination techniques?

A
  • Inspection
  • Palpation
  • Percuss
  • Auscultation
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12
Q

Explain inspection:

A

Visual inspection performed in a methodical and deliberate manner.

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13
Q

Explain palpation:

A

Specialized use of touch that augments the inspection process.

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14
Q

Explain percuss:

A

Striking the body surface with one or both hands to produce a percussive note.

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15
Q

Explain auscultation:

A

Listening to body sounds with a stethoscope.

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16
Q

What are the types of data?

A
  • Subjective

- Objective

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17
Q

Explain subjective data:

A

Patients feelings and statements about their health problems.

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18
Q

Explain objective data:

A

Observable, perceptible, and measurable data

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19
Q

What are sources of data?

A
  • Primary: The patient

- Secondary: All other sources of data, including diagnostic test

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20
Q

Data validation increases the likelihood that cues and inference are what?

A
  • Accurate
  • Free from bias
  • Interpreted correctly
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21
Q

What are the frameworks for assessment data organization?

A
  • Functional health approach
  • Head-to-Toe model
  • Body systems model
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22
Q

What is the second phase of the nursing process?

A

Nursing diagnosis (clinical judgement)

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23
Q

What are components of the nursing diagnosis?

A
  • Diagnostic label
  • Descriptors
  • Definition
  • Defining characteristics
  • Related factors
  • Risk factors
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24
Q

Explain diagnostic label:

A

Name of nursing diagnosis.

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25
Q

Explain descriptors:

A

Words that describe changes in condition, state, or some qualification of the nursing diagnosis.

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26
Q

Explain definition:

A

Describes the characteristics of the human response under considerations.

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27
Q

Explain defining characteristics:

A

The observable cues or inferences that cluster as manifestations of an actual illness or wellness health state, or nursing diagnosis.

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28
Q

Explain related to factors:

A

Describe the conditions, circumstances, or etiologies that contribute to the problem.

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29
Q

Explain risk factors:

A

Environmental factors, physiological, psychological, genetic, or chemical elements that increase vulnerability of an unhealthful event.

30
Q

Explain cue clustering:

A

Analyzing individual cues and fitting them to describe a specific patient problem.

31
Q

Explain cue interpretations:

A

Synthesizing the derived cue clusters to derive the meaning and implications of the human response of a patient.

32
Q

What are the two stages of diagnostic validation?

A
  • Stage 1: interpreted cue clusters are compared with norms for the patient and for patients in general.
  • Stage 2: The formulated nursing diagnosis is evaluated for its research nursing base.
33
Q

What are types of nursing diagnosis statements?

A
  • Actual nursing diagnosis
  • Risk nursing diagnosis
  • Wellness nursing diagnosis
  • Possible nursing diagnosis
34
Q

Explain outcome identification:

A

Formulation of goals and measurable outcomes that provide the basis for evaluating nursing diagnoses.
(Establishing priorities, pt. goals and outcome criteria)

35
Q

Explain planning:

A

Development of nursing strategies designed to ameliorate patient problems: used to direct nursing activities.
(planning interventions and writing pt. plan of care)

36
Q

What is a nursing-sensitive outcomes classification? (NOC)

A

A system organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes.

37
Q

Explain a nursing intervention classification system (NIC):

A

A system organized according to three-level taxonomy consisting of domains, classes, and interventions.

38
Q

What phase of the nursing process of NIC’s used?

A

Planning phase

39
Q

Interventions include nurse-initiated interventions as well as what?

A

Treatments initiated by physicians or other providers.

40
Q

The patient plan of care must what?

A
  • Be developed by RN
  • Be documented in health record
  • Reflect standards of care
41
Q

What are important concepts in developing a patient plan of care?

A
  • Patient-centered

- Reflects step-by-step process

42
Q

Explain instructional plans of care:

A

Care plans for students to create using nursing process

43
Q

Explain Instructional concept maps:

A

A graphical tool for organizing and representing knowledge used in nursing education.

44
Q

Explain clinical plans of care:

A

Plan organized in practical, concise format for daily use.

45
Q

What are instructional patient plans of care components?

A
  • Nursing diagnosis
  • Patient goals
  • Patient outcome criteria
  • Nursing interventions
  • Scientific rationale
  • Evaluation
46
Q

What are types of clinical plans of care?

A
  • Individual plan of care
  • Standard plan of care
  • Generic plan of care
  • Computerized plan of care
47
Q

What are clinical patient plans of care components?

A
  • Assessment and data collection
  • Nursing diagnosis or problem list
  • Outcome identification
  • Interventions
  • Rationale
  • Evaluation
48
Q

Explain implementation:

A

The action phase of the nursing process in which nursing care is provided as per the patient plan of care and nursing actions are recorded.

49
Q

Explain Evaluation:

A

The thorough systematic review of the effectiveness nursing interventions and a determination of patient goal achievements.

50
Q

What activities are included in the implementation phase?

A
  • Reassessing
  • Setting priorities
  • Preforming nursing interventions
  • Recording nursing actions
51
Q

What is the purpose of the implementation phase?

A

To provide the technical and therapeutic nursing care required to help the patient achieve an optimal level of health.

52
Q

What are skills needed for implementation?

A
  • Intellectual
  • Interpersonal
  • Technical
53
Q

Explain intellectual skills:

A

Problem solving, decision making, and teaching skills.

54
Q

Explain interpersonal skills:

A

Verbal and nonverbal communication skills.

55
Q

Explain technical skills:

A

Ability to use equipment, machines, and supplies to render nursing care.

56
Q

What are types of nursing interventions?

A
  • Cognitive
  • Interpersonal
  • Technical
57
Q

Explain cognitive nursing interventions:

A

Educational, delegation, and supervisory.

58
Q

Explain interpersonal nursing interventions:

A

Coordinating, supportive, and psychosocial.

59
Q

Explain technical nursing interventions:

A

Maintenance, Surveillance, Psychomotor

60
Q

What are types of evaluation?

A
  • Structure
  • Process
  • Outcome
61
Q

Explain structure evaluation:

A

Attributes of the setting or surroundings.

62
Q

Explain process evaluation:

A

Nurse’s performance.

63
Q

Explain outcome evaluation:

A

Patient and patient’s function.

64
Q

What are evaluation phase activities?

A
  • Reviewing patient goals and outcome criteria
  • Collecting data
  • Measuring goal attainment
  • Recording judgements or measurements of goal attainment
  • Revising or modifying the patient’s plan of care
65
Q

What is Quality Improvement (QI)?

A

Involves measuring the extent to which standards have been achieved.

66
Q

What are requirements for the effective use of the nursing process?

A
  • Listening
  • Collaboration
  • Communication
67
Q

Explain listening:

A

Includes being responsive to both verbal information and nonverbal cues that patients send.

68
Q

Explain collaboration:

A

Based on positive professional relationships which are built on trust and respect for the unique contribution of each healthcare team member.

69
Q

Explain communicating:

A

Ecompasses effective written and spoken mode as wee as the ability to document accurately by electronic means. Also having ability to translate medical terms to patients and other healthcare professionals.

70
Q

Critical thinking includes what components?

A
  • Technical skills
  • Interpersonal skills
  • Theoretical knowledge
  • Critical thinking attitudes and behaviors

Foundations Exam 2 (5 decks)

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