chapters 33-37 & 101-103 Flashcards
(176 cards)
0
Q
The systematic method in which the nurse and client work together to plan and carry out effective nursing care (steps include assessment, nursing diagnosis, planning, implementation, and evaluation)
A
Nursing process
1
Q
An experimental approach that test ideas to decide which methods work and which do not.
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Trial and error
2
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The basic skill of identifying a problem and taking steps to resolve it
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Problem solving
3
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Precise method of investigating problems and arriving at solutions
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Scientific problem solving
4
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Mix of inquiry, knowledge, intuition, logic, experience, and common sense.
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Critical thinking
5
Q
NCP
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Nursing care plan
6
Q
Guidelines used by healthcare facilities to plan the care for clients
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Nursing care plans
7
Q
The systematic and continuous collection and analysis of data/information about a client
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Nursing assessment
8
Q
The statement or label of the clients ACTUAL or potential problem
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Nursing diagnosis
9
Q
The development of goals for care and possible activities to meet them
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Planning
10
Q
The giving of actual nursing care
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Implementation
11
Q
The measurement of the effectiveness of nursing care
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Evaluation
12
Q
The nursing process is…
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Systematic, client oriented, goal oriented, continuous, and dynamic
13
Q
Specific, orderly, and logical steps based on the clients most important and vital needs
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Prioritization
14
Q
The needs of the client are identified, not the needs of the nurse, family or other healthcare providers
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Client oriented
15
Q
Goals, objectives, or expected outcomes are established as a part of the nursing process.
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Goal oriented
16
Q
The nursing process consists of the following steps:
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Nursing assessment Nursing diagnosis Planning Implementation Evaluation
17
Q
Nurses and clients work together as partners to…
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Promote health
Prevent disease/illnesses
Restore health
Facilitate coping with altered functioning
18
Q
In the nursing process, needs which may occur identified as “at risk for”..
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Potential needs
19
Q
All measurable and observable pieces of information about the client and his or her overall state of health. Only precise, accurate measurements or clear descriptions are used.
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Objective data
20
Q
Clients opinions or feelings about what is happening. Only the client can tell you that he or she is afraid or has pain. Communicating via body language, gestures, facial expressions
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Subjective data
21
Q
Things that you directly see or measure
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Objective data
22
Q
Things the client feels and expresses either verbally or non verbally
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Subjective data
23
Q
An assessment took that relies on the use of the five senses
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Observation
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5 senses of observation
Visual observation
Tactile observation
Auditory observation
Olfactory or Gustatory Observation
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Way of soliciting information from the client
Health interview or nursing history
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Interview conducted when a client is admitted to a healthcare facility
Admission interview
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Physician obtaining information from an admission interview
Medical history
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Documentation by nurses of care given and observations made, charting data input
Nursing progress notes
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Components of nursing history/health interview
Biographical data: name age DOB
Reason for coming to facility: the primary reason or clients chief complain (CC) or perception of illness
Recent health history
Important medical history
Pertinent psychosocial information: addresses family relationships, employment, living condition
Activities of daily living (ADL)- how well client is able to meet basic needs, eating, drinking, bathing etc.
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Analyzing each piece of information to determine it's relevance to a clients health problems and it's relationship to other pieces of information
Data analysis
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NANDA
North American Nursing Diagnosis Association
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Identifies the disease a person had or is believed to have which provides a basis for prognosis and treatment decisions
Medical Diagnosis
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Projected client outcome
| A medical diagnosis provides a basis for this and medical treatment decisions
Prognosis
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Three part nursing diagnostic statement
Problem, etiology, signs and symptoms (airway clearance, excessive mucus, wheezes)
Problem, cause, symptoms
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Portion of nursing diagnostic statement that describes clearly the problem the client is having
Problem
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The part of the nursing diagnostic statement that is the cause of the problem
Etiology
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The third part of the nursing diagnostic statement that summarizes all the data (how the client feels)
Signs and symptoms
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AEB
As evidenced by
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You will work together with the physician or the healthcare providers
Collaborative problem
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PRN
As needed
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The nursing diagnosis is a statement about the clients actual or potential health concerns that can be managed through:
Independent nursing interventions by establishing data and writing a 2-3 part diagnostic statement
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The development of goals to prevent, reduce, or eliminate problems and to identify nursing interventions that will assist clients in meeting these goals
Planning
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A measurable client behavior that indicates whether the person has achieved the expected benefit of nursing care, may also be called goal or objective.
Expected outcome
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Expected outcome includes:
Client oriented, specific, reasonable, measurable
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An expected outcome it goal that a client can reasonably meet in a matter of hours or a few days
Short term objective
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Outcome that the client ultimately hopes to achieve but which requires a longer period of time to accomplish
Long term objective
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Activities (actively doing something) that will most likely produce desired outcomes (short term/long term)
Ex: teaching client deep breathe exercises, offering fluids frequently.
Nursing intervention
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The entire nursing team usually formulated the nursing care plan at a meeting called...
The nursing care conference or team conference
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Nursing care plan must exist within how many hours?
12-24 hours
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Steps in Planning are:
Setting priorities
Establishing expected outcomes
Selecting nursing interventions
Writing a nursing care plan
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The carrying out of nursing care plans, also called interventions •just do it•
Implementation
52
Nursing implementation performs 3 actions...
Dependent actions
Interdependent actions
Independent actions
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Actions that carry out a physicians orders regarding medication or treatments (MD/physicians requires)
Dependent actions
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Perform collaborative with other care providers. Interventions for collaborative problems.
Ex: a physician writes an order to give a client an enema when necessary, the nurse uses their best judgement to determine when client needs enema
Interdependent action
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Nursing actions that do not require a physicians orders based on the nurses judgement (bathing, toileting)
Independent actions
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A legal requirement in nursing practice in which you the nurse are responsible for all your actions you perform, whether they are dependent, interdependent, independent.
Accountability
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Knowing and understanding essential information before caring for clients (critical thinking is an example)
Intellectual skills
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Believing, behaving, and relating to others
Interpersonal skills
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Changing a sterile dressing or administering an injection is what kind of skill?
Technical skills
60
Nursing implementation means the carrying out of the nursing care plan which includes 4 steps:
Putting the nursing care plan into action
Continuing the collection of data
Communicating care with the healthcare team
Document care
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Communication with the health care team
Client planning conference
| Or discharge planning conference (if client is being discharged)
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Measuring the effectiveness of assessing, diagnosing, planning, and implementing.
Evaluation
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Steps in evaluation for nursing care
Analyzing the clients responses
Identifying factors contributing to success or failure
Planning for future care (discharge planning)
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3 means to evaluate the effectiveness of nursing care
the client
Team conference
Community health agencies
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The process by which the client is prepared for continued care outside the healthcare facility or for independent living at home
Discharge planning
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Manual or electronic account of a clients relationship with a healthcare facility
Health record
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Accurate and complete documentation in a clients health record is an essential communication tool because...
Maintains communication among all caregivers
Provides written evidence of accountability
Meets legal, regulatory, and financial requirements
Provides data for research and educational purposes
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Health record that supports the healthcare agency and providers have acted responsibly and effectively
Documented evidence
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If it was not documented...
It was NEVER done
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Standards of care (regulatory requirements for document keeping)
Record keeping
Providing safe and effective healthcare and verifying it through QA
Complete and accurate healthcare records
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Financial accountability (health record)
Clients and third party payers depend on complete list of services and products provided before paying for healthcare. All treatments must be given, examinations, and special
Equipments used and recorded in health care records
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Electronic documents found in a computer network
Medical information system - MIS
| Electronic medical records - EMRS
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Collection of various forms and documents (binder, notebook in nurses station or main administration office)
Manual health record
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Documentation systems include -
EMR, MIS, or manual record/binder notebook
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Health records contain four categories:
Assessment documents
Plans for care and treatment
Progress records
Plans of continuity of care
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Documents that record all information about the client obtained through interview, examination, diagnostic procedures, or consultation.
Assessment documents
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Long term care and some home cares use a standard form as part of the admitting nursing history / measures a clients ability to perform the activities of daily living and identifies functional losses that affect this ability
Minimum data set (MDS)
| Resident assessment protocol (RAP)
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Purpose for the plans of care
To ensure that all caregivers provide the same care and treatments for the client
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The development of planning care used both
LPN/LVN and RNs
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The physicians plan of care contains goals for treating the client and specific instructions to guide the nursing staff
Orders
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A plan that specifies expected outcomes and treatments at specified times for all members of the healthcare team
Clinical care path
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Establish a baseline of data
Enter data at regular intervals
Summarize the clients condition
Document changes in clients condition
Document a response to treatment.
```
Progress notes
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Demonstrates how the nursing process and diagnoses are used to create collaboration and consistency for client care
NANDA-I
| North American nursing diagnosis association international
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Narrative- Chronological
Summarizes the progress of the client toward achieving his or her care plan goals
Progress or nurses notes
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Type of nurses note that essentially documents what is occurring throughout the day in a chronological manner.
Narrative charting
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Body system assessment starting with general observation, than assessments of the neurological, integumentary, cardiovascular, gastrointestinal, and genitourinary systems.
Head to toe charting
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Type of charting used to focus on specific problems
Focus charting or area charting
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The whole healthcare team works collaboratively to identify priority problems and they work collectively to solve these problems
Problem-oriented medical records (POMR)
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Type of charting: SOAP
Subjective
Objective
Assessment/Analysis
Plan
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SOAPIER
```
Subjective
Objective
Assessment/analysis
Plan
Intervention
Evaluation
Revision
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APIE
Assessment
Plan
Intervention
Evaluation
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Seperate notes by physicians, nurses, dietary, healthcare team members used as specific forms for a particular field
Documentation by discipline
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Type of narrative charting that usually used a flow sheet listing body systems and their typical findings, such as lung sounds: clear, crackles, or rhonchi. The nurse checks off the correct assessment findings on a sheet
Charting by exception - CBE
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This type of narrative charting would be best for a client who is physically stable with an uncomplicated care plan
Charting by exception : CBE
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Emphasis is on quality care that is delivered in the most cost effective manner - also known as case studies, care mapping, critical pathway, and collaborative pathways
Case management
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A graph, form, or picture that records large amounts of information collected at intervals over a specified period in brief concise entries
Graphic flow chart
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Lists all medications that the physician has ordered for the client, with spaces for the caregiver to mark when medications are given
Medication administration record : MAR
98
Graphic flow sheet include:
Vital signs, intake and output, ADLs, dietary or eating patterns, neurological checks, restraint observation and documentation, frequent blood sugar monitoring, postoperative records, wound care and monitoring
99
Skills in documentation
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Document what you see
Be specific
Use direct quotes
Be prompt
Be consistent
Record all relevant information
Respect confidentiality
Record documented errors
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Error in documenting/ Recorded in error - RIE
Draw a line through the statement, enclose in parenthesis and write ERROR and your initials next to it. Original note must be readable.
(mistaken entry)
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AC
Before meals
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ABG
Arterial blood gas
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Ad lib
As desired
| At liberty
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AEB
As evidenced by
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AMB
As manifested by
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AMA
Against medical advice
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Amb
Ambulate
108
BM
Bowel movement
109
BID
Twice per day
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BRP
Bathroom privileges
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Cc
Chief complaint
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C/o
Complains of
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CPR
Cardiopulmonary resuscitation
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DNR
Do not resuscitate
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DSG
Dressing
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Dx
Diagnosis
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FOB
Foot of bed
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Fx
Fracture
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Gtt
Drops
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H or hr
Hour
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HOB
Head of bed
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Hx
History
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I&O
Intake and output
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IM
Intramuscular
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IV
Intravenous
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KVO, TKO
Keep vein open, to keep open
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L
Left
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L
Liter
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LMP
Last menstrual period
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MEq
Milliequivalent's
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NG
Nasogastric
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NKA
No known allergies
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Npo
Nothing by mouth
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NS
Normal saline
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N/V or N/V/D
Nausea and vomiting ; nausea, vomiting, diarrhea
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O
Oral
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PC
After meals
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PO
By mouth
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PR
Per rectum
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Pulse ox
Pulse oximetry
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Q, q
Every
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Qh
Every hour
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R, r
Respiration, rectum
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rt
Right
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S/P, s/p
Status post, after
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STAT
Immediately
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Subq
Subcutaneous
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Supp
Suppository
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Susp
Suspension
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S&S
Signs and symptoms
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Sx
Symptoms
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TF
Tube feeding
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TPN
Total parenteral nutrition
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TPR
Temperature, pulse, respiration
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TX, Tx
Treatment
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VS
Vital signs
157
ROM
Range of motion
158
Caregivers move from client to client discussing important information
Walking rounds
216
Exchanging of information between the outgoing and incoming staff on each shift given verbally in person, in writing, or by tape recorder
Change of shift reporting
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CAT
Computer adaptive test
218
The LPN does not perform nursing assessment per se and does independently develop nursing care plan
Good fact
219
The four phases of nursing process associate a to NCLEX-PN examination include:
Data collection
Planning
Implementation.
Evaluation
220
CLTC
Certified in long term care for lpns
221
A person who used specific skills such as role modeling
Leader
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Coordinates and controls the work of others
Manager
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Behavior used by a leader in a specific situation
Leadership style
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Leader makes decisions and the group is expected to carry out orders (dictatorship)
Autocratic leadership
225
Leadership that relies on policies and procedure manual of the healthcare facility
Bureaucratic leadership
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Guiding staff in the right direction by using a free flow of ideas, plans, and information between leaders and followers
Democratic leadership
227
Loosely structured goals with no firm guidelines, encourages followers to choose their own goals and plans to implement. Trying new things without fear of mistakes
Laissez- faire leadership
228
Writing summary evaluations of staff members (charge nurse writes this)
Performance reviews
229
First step if employee is showing deficiencies in due process
Oral reprimand p
230
If deficiency continues after oral reprimand... The second process is
Written reprimand
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Procedure that ensures fair labor practices for employees and employers
Due process
232
A plan made for an employee who has not followed or improved deficiency after being orally and written reprimand
Plan of assistance
