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Foundation of Professional Nursing > Chapter 14-19 > Flashcards

Chapter 14-19 Flashcards

1
Q

Systematic

A

Part of an ordered sequence of activities

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2
Q

Dynamic

A

Great interaction and overlapping among the five steps.

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3
Q

Interpersonal

A

Human being is always at the heart of nursing.

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4
Q

Outcome Oriented

A

Nurses and clients work together to identify outcomes.

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5
Q

Universally Applicable

A

A framework for all nursing activities

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6
Q

Benefits of the nursing process

A

Client
-Scientifically based, holistic individualized client care
-Continuity of care
-Clear, efficient, cost-effective plan of action

Nurse
-Opportunity to work collaboratively with other healthcare workers
-Satisfaction of making a difference in lives of clients
-Opportunity to grow professionally

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7
Q

Critical Thinking & Clinical Reasoning

A
  • is purposeful, informed, outcome-focused thinking
    -is driven by client, family, and community needs
    -uses both intuition and logic, based on knowledge, skills, and experience
    -requires strategies that make the most of human potential
    -is constantly reevaluating, self-correcting, and striving to improve.
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8
Q

Assessment

A

-Systematic, dynamic way to collect and analyze data about a client
-includes physiological, psychological, sociocultural, spiritual, economic, and life-style factors.
-primary source of information is from the client

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9
Q

Types of Assessments

  • Initial Nursing Assessment
A

-Shortly performed after client is admitted to the health care facility

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10
Q

Types of Assessments

-Focused Assessment

A

-information gathered about a diagnosed condition

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11
Q

Types of Assessments

-Emergency Assessment

A

-Client presents with physiological crisis to identify life-threatening problem

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12
Q

Types of Assessments

-Time-lapsed Assessment

A

-compares a current assessment to a baseline assessment

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13
Q

Data Collection
(Purpose)

A

Purposes
-Health Status
-Health problem identification

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14
Q

Data Collection
(Methods of Collection)

A

-Examination
-Observation
-Interviewing

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14
Q

Data Collection
(Types)

A
  1. Subjective
  2. Objective
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15
Q

Data Collection
(Characteristics)

A

-Purposeful
-Complete
-Factual & Accurate
-Relevant

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16
Q

Data Collection
(Sources)

A
  • Client
    -Family/Significant others
  • Client Record
    -Other healthcare professionals
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17
Q

Objective Data

A
  • Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
    (For example, elevated temperature, skin moisture, vomiting)
18
Q

Subjective Data

A

-information perceived only by the affected person
(For example, pain experience, feeling dizzy, feeling anxious)

19
Q

The Skill of Nursing Observation

A
  1. Determines the client’s current responses (physical and emotional)
  2. Determines the client’s current ability to manage care.
  3. Determines the immediate environment and its safety.
  4. Determines the larger environment (hospital and community)
20
Q

Successful Interview Techniques

A
  1. Focus on the client during the interview
  2. Listen to the client attentively.
  3. Ask about client’s main problem first.
  4. Pose questions and comments in appropriate manner.
  5. Avoid comments and questions that impede communication.
  6. Use silence and touch appropriately.
21
Q

Type of Questions used in Interviews

A
  1. Open-ended-allow client to verbalize freely.
  2. Closed- elicit specific information.
  3. Validating- Validate what is heard.
  4. Clarifying- avert misconceptions.
  5. Reflective- encourage client to elaborate on thoughts and feelings.
  6. Sequencing- place events in chronological order
  7. Directing- Obtain more client information.
22
Q

Documentation of Data

A
  1. Immediately give verbal reporting of data whenever a critical change in the client’s health status is assessed.
  2. Enter initial database into computer or record in ink on designated forms the same day client is admitted.
  3. Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
  4. Use good grammar and standard medical abbreviations.
  5. Whenever possible use client’s own words.
  6. Avoid nonspecific terms subject to individual interpretation or definition.
23
Q

Nurse Concerns and Responsibilities

A
  1. Recognizing signs and symptoms of common health problems and those that may indicate the need for more expert diagnosis.
  2. Predicting problems in those at risk and taking steps to manage risks and prevent complications.
  3. Identifying human responses and promoting optimum function, independence, and quality of life.
  4. Initiating actions and referrals in a timely way to ensure appropriate, qualified treatment.
24
Q

Purpose of the Diagnosing Step

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 upon which the individual, group, or community can draw to prevent or resolve problems.
25
Q

Types of Diagnoses

Nursing Diagnosis

A

-Describes client problems nurses can treat independently

26
Q

Types of Diagnoses

Medical Diagnoses

A

-describes problems for which the physician directs the primary treatment

27
Q

Types of Diagnoses

Collaborative Problems

A

-managed by using physician-prescribed and nursing-prescribed interventions

28
Q

Steps of Data Interpretation & Analysis

A
  1. Recognizing significant data (comparing data to standards)
  2. Recognizing patterns and clusters
  3. Identifying strengths and problems
  4. Reaching conclusions
    -No problem
    -Possible problem
    -Actual or potential problem
    -Clinical problem other than nursing diagnosis
29
Q

Formulation of Nursing Diagnosis

*Problem

A

identifies what is unhealthy about client
-Addresses the human response
-NANDA (North American Nursing Diagnosis Association)

30
Q

Formulation of Nursing Diagnosis

*Etiology

A

identifies factors maintaining the unhealthy state
-related to (r/t)

Example: Acute pain r/t myocardial ischemia

31
Q

Formulation of Nursing Diagnosis

*Defining Characteristics

A

identifies the subjective and objective data that signal the existence of a problem.
-As evidence by (AEB)

Example: AEB c/o radiating chest pain to neck and left jaw

32
Q

Goal of Outcome Identification & Planning Step

A
  1. Establish priorities
  2. Identify and write expected client outcomes.
    SMART GOALS:
    -Specific
    -Measurable
    -Attainable
    -Relevant
    -Time bound
  3. Select evidence-based nursing interventions.
  4. Communicate the plan of care
33
Q

SMART GOALS

A

-Specific
-Measurable
-Attainable
-Relevant
-Time bound

34
Q

Elements of Comprehensive planning

-Initial

A
  1. Developed by the nurse who performs the nursing history and physical assessment.
  2. Addresses each problem listed in the prioritized nursing diagnoses.
  3. Identifies appropriate client goals and related nursing care.
35
Q

Elements of Comprehensive planning

-Ongoing

A
  1. Carried out by any nurse who interacts with a client.
  2. Keeps the plan up to date.
  3. States nursing diagnoses more clearly.
  4. Develops new diagnoses.
  5. Makes outcomes more realistic and develops new outcomes as needed.
  6. Identifies nursing interventions to accomplish client goals
36
Q

Elements of Comprehensive planning

-Discharge

A
  1. Carried out by the nurse who worked most closely with the client.
  2. Begins when the client is admitted for treatment.
  3. Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently.
37
Q

Types of Nursing Interventions

Nurse-initiated

A

actions performed by a nurse without a physician’s order
-Independent actions
-protocols
-standing orders

38
Q

Types of Nursing Interventions

Physician-initiated

A

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

39
Q

Types of Nursing Interventions

Collaborative

A

treatments initiated by other providers and carried out by a nurse.
-dependent actions

40
Q

Evaluation of Nursing Interventions

A
  1. Were the goals met?
    -No further interventions required
    -Ongoing monitoring
  2. If goals were not met?
    -Does the nurse need to change or revise interventions?
41
Q

Essentials of Effective Delegation

A
  1. Know your state and institutional policies on delegation.
  2. Be clear on the differences between nursing process and nursing task.
  3. Know the training and background of the unlicensed assistive personnel.
  4. Know the client’s needs and what he or she is at risk for.
  5. Know what clinical cues the UAP should be alert for and why.
  6. Assess which tasks can be safely delegated.
42
Q

Rights of Delegation

A
  1. Right Person
  2. Right Task
  3. Right Circumstance
  4. Right Directions
  5. Right Communication
  6. Right Supervision
  7. Right Evaluation

Foundation of Professional Nursing (1 decks)

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