Lesson 1 Flashcards
(21 cards)
ANA
American Nursing Association
What is the ANA 6 step nursing process?
Assessment Diagnosis Outcomes identification Planning Implementation Evaluation
What is the most accurate way to asses a 2 year old’s pulse?
Apical.
Over 2 and radial is effective.
What is the law that regulates nurses practice in each state?
State nurse practice act
Sometimes, instead of performing a complete H&P, you may perform only selected portions. What is this called?
Focused health data assessment
Repeated assessment obtained to compare data collected at one or more points in time with baseline data.
Time-lapsed nursing assessment
Information obtained from the patient.
Primary data
Information obtained from sources other than the patient.
Secondary data
Sum of all primary and secondary information.
Patient database
What are the 3 primary data collecting tools?
Observation
Interview
Examination
What are the 5 components of a NANDA nursing diagnosis?
Diagnostic Label Definition Defining characteristics (signs/symptoms) Risk Factors Related Factors
What are the 4 types of NANDA nursing diagnoses?
Actual Diagnosis
Health promotion diagnosis
Risk Diagnosis
Syndrome Diagnosis
A diagnosis that is being investigated but not yet confirmed.
Possible diagnosis
EHR
Electronic Health Records
As constructed by NANDA, how many “axis” are used in constructing a diagnosis?
7
Name the 7 NANDA axis used in diagnosis construction.
- Diagnostic focus
- Subject of the diagnosis
- Judgement
- Location (body system, body location)
- Age
- Time (duration, chronic, acute, etc)
- Status (actual, health promotion, syndrome, etc)
What are the 5 levels of Maslow’s hierarchy of needs?
- Physiologic
- Safety and security
- Love and belonging (social)
- Self-esteem
- Self-actualization
When does discharge planning begin?
At the time of admission to the nursing unit.
What is the difference between independent and dependent interventions?
Independent: routine tasks such as repositioning a patient
Dependent: requires permission or oversight from a physician - e.g. Medication administration
Evaluations of outcomes performed prior to discharge, or prior to case closure.
Terminal evaluation.
What is the Excelsior 5-step nursing process?
Assessment Analysis Planning Implementation Evaluation
