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1
Q

is a systematic problem solving process that guide all nursing actions.

A

Nursing Process

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2
Q

This is the type of thinking and doing that nurses use in their practice (ANA, 2004).

A

Nursing Process

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3
Q

Organized Systematic
Goal - oriented
Humanistic care
-leads to ?

A

Effective and Efficient NP

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4
Q

Introduced three steps of nursing process in 1959

A

Dorothy Johnson

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5
Q

Dorothy Johnson’s 3 Steps in Nursing Process

A

Assessment
Decision
Nursing action

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6
Q

Originated nursing process in 1955

A

Lydia Hall

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7
Q

Lyda Hall three steps in Nursing Process

A

Note Observation
Ministration of care
Validation

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8
Q

Identified three steps of nursing process: 1961

A

Ida Jean Orlando

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9
Q

Ida Jean Orlando Nursing Process steps

A

Clients behavior
Nurse’s reaction
Nurse’s actions

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10
Q

has the four components of nursing process: 1967

A

Yura and Walsh

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11
Q

Yura and Walsh has the four nursing components of nursing process:

A

Assessing
Planning
Implementing
Evaluating

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12
Q

Described nursing process in 1967

A

Discover
Delve
Do
Decide
Descriminate

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13
Q

True or False
ANA: Diagnosis distinguished as a separate step of nursing process 1973

A

True

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14
Q

True or False
ANA :Diagnosis of actual and potential health problems delineated as integral part of nursing practice. 1973

A

False;1980

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15
Q

• differentiated as a distinct step of the nursing process. (ADOPIE)

A

Outcome identification

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16
Q

A systematic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client (ANA, 2004).

A

Assessment

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17
Q

Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle

A

Assessment

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18
Q

Types of Data

A

Subjective and Objective Data

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19
Q
  • “Symptoms” or covert data
A

Subjective Data

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20
Q

-Client’s sensation, feelings, values, beliefs, attitudes, perception of personal health status and life situation.

A

Subjective Data

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21
Q

Information told to the nurse

A

Subjective Data

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22
Q
  • “signs” or Overt data
A

Objective Data

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23
Q
  • Vital signs results, x-ray test results, skin color and urine output.
A

Objective Data

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24
Q

Information gathered through a physical assessment or from laboratory or diagnostic test.

A

Objective Data

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25
True or False Objective Data: It can be measured or Observed by the nurse or other health care providers What the nurse Observes
True
26
Gathering information about the client’s status
Data collection
27
Sources of Data
Primary Data Secondary Data
28
Subjective or objective data obtained from the client: what the client says or what you observe.
Primary Data
29
All sources other than the client - Significant others - Client records - Health care professionals
Secondary Data
30
Methods of Data Collection
Observation Interview
31
-"All that you see,smell or sense becomes data in the context
Observation
32
• planned communication or a conversation with a purpose.
Interview
33
True or False Observation is the Deliberate use of all five senses to gather and interpret patient and environment.
True
34
• Purposeful, structured communication in which you question the patient to gather subjective data for the nursing databas
Nursing Interview
35
Focus of Nursing Interview
Focus: • Establishing rapport • Gather information •
36
• Is the second step of Nursing Process • The nurse analyzes the assessment data in determining Diagnoses.
DIAGNOSIS
37
True or False the nurse analyzes the data gathered during assessment and identifies problem areas for the patient. The nurse then makes a nursing diagnosis.
True
38
applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-I-approved nursing diagnosis
Nursing diagnosis
39
is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat.
Medical Diagnosis
40
There are three steps in the diagnosis step:
Data Analysis Problem identification Formulation of Nursing Diagnosis
41
COMPONENTS OF A NURSING DIAGNOSIS
Problem statement/Diagnostic label Etiology Risk Factors Defining Characteristics
42
describes the client's health problem or response for which nursing therapy is given as concisely as possible.
Problem statement/Diagnostic label
43
Problem Statement/Diagnostic Label two parts
two parts: QUALIFIER & FOCUS (of the diagnosis)
44
: -are words that have been added to some NANDA label to give additional meaning to the diagnostic statement:
QUALIFIERS
45
Deficient - Impaired- Decreased - Ineffective - Compromised -
Deficient - (inadequate in amount, quality, or degree; not sufficient; incomplete) Impaired - (made worse, weakened, damaged, reduced, deteriorated) Decreased - (lesser in size, amount, or degree) Ineffective - (not producing the desired effect) Compromised - (to make vulnerable to threat).
46
- Also known as "related factors" - component of a nursing diagnosis label that identifies one or more probable causes of the health problem,
Etiology
47
- are used instead of etiological factors for risk nursing diagnosis.
Risk Factors
48
- are forces that puts an individual (or group) at an increased vulnerability to an unhealthy condition.
Risk factors
49
- the conditions involved in the development of the problem - gives direction to the required nursing therapy - enables the nurse to individualize the client's care.
Etiology
50
True or False Etiology is linked with the problem statement with the phrase "related to".
True
51
- the clusters of signs and symptoms that indicate the presence of a particular diagnostic label.
Defining Characteristics
52
True or False Defining characteristics are written following the phrase "as evidenced by" or "as manifested by" in the diagnostic statement.
True
53
the defining characteristics are the identified signs and symptoms of the client.
Actual Nursing Diagnosis
54
no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis.
For risk nursing diagnosis
55
TYPES OF NURSING DIAGNOSIS
ACTUAL NURSING DIAGNOSIS RISK NURSING DIAGNOSIS POSSIBLE NURSING DIAGNOSIS WELLNESS DIAGNOSIS SYNDROME DIAGNOSIS
56
- is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms.
ACTUAL NURSING DIAGNOSIS
57
refers to the problem that"exist at the present moment.'
Actual Nursing Diagnosis
58
Actual Nursing Diagnosis Formula
Patient's Problem + Causes if Known = Actual Nursing Diagnosis
59
- These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.
RISK NURSING DIAGNOSIS
60
FORMULATING A RISK NURSING DIAGNOSIS
Problem Statement + Risk Factors = At Risk/High Risk Nursing Diagnoses
61
- a clinical judgment that is more vulnerable to develop the problem.
Risk Reduction Diagnosis
62
- Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem.
POSSIBLE NURSING DIAGNOSIS
63
- the nurse may decide to formulate a tentative or possible nursing Diagnosis
Possible Nursing Diagnosis
64
Possible Nursing Diagnosis
Possible+Diagnostic Label
65
- Also known as Health promotion diagnosis - is a clinical judgment about motivation and desire to increase well-being.
Wellness Diagnosis
66
True or False Components of a health promotion diagnosis generally include only the diagnostic label or a one-part-statement. It may also include a defining characteristic.
True
67
Wellness Diagnosis Formula
Health Promotion Label + defining Characteristics
68
Data may include the following dimensions:
physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle

Fundamentals (5 decks)

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