Nursing Process Flashcards
(90 cards)
1
Q
4 skills necessary to performs the nursing process
A
- critical thinking
- critical reasoning (evidence based practice)
- communication
- concept based learning
2
Q
6 phases of nursing process
A
- assessment
- diagnosis
- outcome
- planning
- implementation
- evaluation
3
Q
What happens during assessment phase?
A
- collection of subjective and objective data
- holistic
- information gathered about past and present
4
Q
Primary Source in assessment
A
Patient
5
Q
Secondary sources in assessment
A
-labs, diagnostic tests, report from someone else (family)
6
Q
How do you collect subjective data?
A
Interview
7
Q
techniques of inspection (palpation, percussion, auscultation)- objective or subjective data?
A
objective
8
Q
measurement devices- - objective or subjective data?
A
objective
9
Q
health record- objective or subjective data?
A
objective
10
Q
laboratory studies/xray/labs/diagnostic procedures - objective or subjective data?
A
objective
11
Q
symptoms - objective or subjective data?
A
objective
12
Q
signs- objective or subjective data?
A
objective
13
Q
feelings/attitudes- objective or subjective data?
A
subjective
14
Q
values/beliefs- - objective or subjective data?
A
subjective
15
Q
what happens in an admission assessment?
A
- health history
- head to toe physical exam
- functional status, collection of data concerning actual or potential dysfunction baseline for reference and future comparison
16
Q
when does a focus assessment occur and what is it?
A
- status determination of a specific problem identified during previous assessment
- a few minutes to hours between assessments
17
Q
What is a time-lapse reassessment?
A
-detection of changes in all functional asreas after an extended period of time has passed
18
Q
How often does time lapse reassessment occur?
A
several months (3-9) between assessments
19
Q
What is an emergency assessment?
A
-identification of life threatening physical or psychological emergency
20
Q
The act of noticing patient cue
A
Observation
21
Q
Interaction and communication process for gathering data by questioning and information exchange
A
interviewing
22
Q
analysis of bodily functioning using the techniques of inspection, palpation, percussion, and auscultation
A
physical examination
23
Q
4 parts of interviewing
A
- preparatory phase
- introductory phase
- maintenance phase
- concluding phase
24
Q
What happens in preparatory phase?
A
- phase 1 of interview
- gather all pertinent information
- determine what info you want
- set the environment
25
What happens in introductory phase of interview?
phase 2 of interview
| -identify self, what you are doing, and how long you are doing it
26
When does introductory phase occur? (frequency)
every time you go in patient room
27
What happens in maintenance phase?
Phase 3 oh interview process
- facilitate dialogue
- answer questions
- focus on task
28
What happens with concluding phase?
phase 4 of interview
- review goal or task attainment
- summarize highlights
- encourage questions
29
4 steps of the physical assessment
1. inspection
2. palpation
3. percussion
4. auscultation
30
Part of the physical assessment that is a visual assessment
Inspection
31
Part of the physical assessment using touch to determine size, shape and configuration of underlying body structures
palpation
32
Part of physical assessment with use of sounds from tapping areas on the body to determine underlying body structure
percussion
33
part of physical assessment using a stethoscope to amplify sound
auscultation
34
What happens in the diagnosis phase of the nursing process?
- phase 2
- human responses to actual or potential healthcare problems
- derived from the assessment data
35
Is the nursing diagnosis the same as a medical diagnosis?
No
36
What institution develops nursing diagnoses
North American Nursing Diagnosis Association (NANDA)
37
4 components of nursing diagnosis
(2nd step in nursing process)
1. diagnostic label
2. related factors
3. Defining characteristics
4. Risk factors
38
What is the diagnostic label? example?
- first part of nursing diagnosis
- something the patient has
ex: deficient knowledge, impaired urinary elim, risk for infection
39
What is related factors part of nursing diagnosis?
- 2nd part
| - medical conditions or circumstances that relate to the problem but do not directly cause it
40
What is the defining characteristic part of nursing diagonsis?
- part 3
- observable cues that support diagnosis
- signs and symptoms
41
what is the risk factor part of nursing diagnosis?
- used in "risk for" diagnosis only**
| - elements that could cause the problem
42
3 part nursing diagnosis has..
- diagnostic label
- related factors
- defining characteristics
43
2 part nursing diagnosis
- diagnostic label
| - risk factors
44
PES format for nursing diagnosis
Problem (diagnostic label)
Etiology (related factors)
Signs/symptoms (defining characteristic)
45
Outcomes need to be...
- measurable
- realistic
- patient- focused
aka: goals
46
The development of a care plan to address the outcomes
Planning
47
What is required for outcome identification?
prioritization
48
How do you determine priority?
- urgency
| - importance
49
After something life threatening what is the next priority?
-pain management
50
What is a nursing intervention?
any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes
51
Types of nursing interventions...
- psychomotor
- psychosocial
- educational
- maintenance
- surveillance
- supervisory
- sociocultural
52
Cognitive, interpersonal or technical nursing intervention:
| Teach/educate
Cognitive
53
Cognitive, interpersonal or technical nursing intervention:
| Relate knowledge to ADLS
Cognitive
54
Cognitive, interpersonal or technical nursing intervention:
| Provide Feedback
Cognitive
55
Cognitive, interpersonal or technical nursing intervention:
| Create strategies for patients with dysfunctional communication
Cognitive
56
Cognitive, interpersonal or technical nursing intervention:
| Delegate to UAP
Cognitive
57
Cognitive, interpersonal or technical nursing intervention:
| Supervising nursing team, patient or family in performance
Cognitive
58
Cognitive, interpersonal or technical nursing intervention:
| Alter environment as needed
Cognitive
59
Cognitive, interpersonal or technical nursing intervention:
| Coordinate activities
interpersonal
60
Cognitive, interpersonal or technical nursing intervention:
| Provide caregiving
interpersonal
61
Cognitive, interpersonal or technical nursing intervention:
| use of therapeutic communication
interpersonal
62
Cognitive, interpersonal or technical nursing intervention:
| provide a personal presence
interpersonal
63
Cognitive, interpersonal or technical nursing intervention:
| set limits
interpersonal
64
Cognitive, interpersonal or technical nursing intervention:
| provide opportunity to examine values and attitudes
interpersonal
65
Cognitive, interpersonal or technical nursing intervention:
| explore and legitimize feelings
interpersonal
66
Cognitive, interpersonal or technical nursing intervention:
| Provide spiritual support
interpersonal
67
Cognitive, interpersonal or technical nursing intervention:
| use humor
interpersonal
68
Cognitive, interpersonal or technical nursing intervention:
| provide individual or group therapy
interpersonal
69
Cognitive, interpersonal or technical nursing intervention:
| be patient advocate
interpersonal
70
Cognitive, interpersonal or technical nursing intervention:"
| make referrals and follow ups
interpersonal
71
Cognitive, interpersonal or technical nursing intervention:
| serve as role model
interpersonal
72
Cognitive, interpersonal or technical nursing intervention:
| support patient and family plans
interpersonal
73
Cognitive, interpersonal or technical nursing intervention:
| provide basic hygeine and skin care
technical
74
Cognitive, interpersonal or technical nursing intervention:
| perform routine nursing activities
technical
75
Cognitive, interpersonal or technical nursing intervention:
| detect change from baseline, reorganize abnormal responses
technical
76
Cognitive, interpersonal or technical nursing intervention:
| assist with ADLS
technical
77
Cognitive, interpersonal or technical nursing intervention:
| provide appropriate sensory stimulation
technical
78
Cognitive, interpersonal or technical nursing intervention:
| mobilize or maintain equipment
technical
79
What is the general format for care plans or concept maps?
- nursing diagnostic statement
- patient goals
- nursing interventions
80
What happens during implementation phase?
(5th part of nursing care plan)
-focus on what nurse will do:
initiation of plan, evaluation of response, reassessment
81
Transfer of responsibility for performance of a task to another individual while retaining accountability for the outcome
delegation
82
If a task is delegated and it does not get completed, who is at fault- nurse or person they delegated to?
nurse
83
5 priniciples of delegation
1. right person
2. right task
3. right circumstance
4. right communication
5. right evaluation
84
Righ tperson- delegation
trained to perform the task, willing, and legally able
85
Right task- delegation
- set procedure
- familiar to person delegated to do it
- involve minimal risk
86
Right circumstance - delegation
-patient must be stable
-able to supervise person performing
(don't have to supervise but must have the ability to do so)
87
Right communication- delegation
communicate what needs to be done and what is expected
88
Right evaluation- delegation
check if the task was performed and documented
| -provide feedback in needed
89
What cannot be delegated to UAP/CNA/LPN(4)
- education
- assessment
- clinical judgement
- evaluation
90
What happens during evaluation?
(last phase of nursing process)
| -was the plan of care successful in addressing the problem
