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Test II N121 > Nursing Process > Flashcards

Nursing Process Flashcards

(70 cards)

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1
Q

Purpose of Nursing Process

A
  1. ID health status, actual/potential problems and needs
  2. Establish plans to meet IDed needs
  3. deliver interventions to meed needs
  4. Evaluate success
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2
Q

Assessment Definition

A

Systematic and continuous collection of data about client focused on client responses to health problem

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3
Q

Types of Assessment

A

Initial, Problem-focused, Emergency, and Time-lapsed

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4
Q

4 Assessment Processes

A
  1. Collecting Data, 2. Organizing Data, 3. Validating data, 4. Documenting Data
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5
Q

subjective data

A

symptoms apparent only to the client, described or varified by client. Client’s sensations, feelings, values, beliefs, attitudes, and perceptions

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6
Q

Objective Data

A

Signs- detectable to observer, measured/tested against standards, can be seen, heard, felt, or smelled

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7
Q

Sources of Data

A

Client (primary/subjective), support people, client records, HCP, Literature

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8
Q

Data Collection Methods

A

Observing, Interviewing, and Examing

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9
Q

Observing

A

Gathering data via senses. conscious and deliberate

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10
Q

Interviewing

A

planned communication/conversation with client. Directive or Nondirective

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11
Q

Examining

A

physical assessment via inspection, auscultation, palpation, and percussion

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12
Q

Organizing Data

A

Use written or digital format to organize assessment data systematically

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13
Q

Validating Data

A

double checking data for consistency and that its complete, factual, and accurate to allow diagnosis and intervention to be based on info

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14
Q

Cues

A

subjective/objective data that can be directly observed by nurse

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15
Q

Inferences

A

Nurse’s interpretation/conclusion made based on cues

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16
Q

Diagnosis Definition

A

statement made by nurse about client’s health problem including: diagnostic label (P), causal relationship (E), and defining characteristics (S/S)

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17
Q

5 Types of Nursing Diagnosis

A

Actual, Risk, Wellness, Health Promotion, and Syndrome

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18
Q

Actual Diagnosis

A

client problem present at time of nursing assessment and is based on presence of S/S

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19
Q

Risk nursing Diagnosis

A

Presence of risk factors indicates that problem is likely to develop e/o interventions

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20
Q

Wellness Diagnosis

A

human response to levels of wellness in client that have a readiness for enhancement

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21
Q

Health Promotion

A

Client’s motivation and desire to increase well-being and actualize health potential

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22
Q

Syndrom diagnosis

A

associated with cluster of other diagnosis

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23
Q

Diagnosis- Problem

A

client’s health problem or response for nursing care to be given. Few words, specific, guiding

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24
Q

Diagnosis- Etiology

A

related factors and risk factors. Probable causes of health problem. Individualizes client care

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25
Diagnosis- Defining Characteristics
signs and symptoms that indicate presence of particular diagnostic label. Signs and symptoms of PROBLEM
26
Steps of Diagnostic Process
Analyzing Data, ID health problems/risks, formulating diagnostic statement
27
Analyzing Data
Diagnostic Process- comparing data against standards, clustering cues, and Final checks for inconsistencies
28
Significant Cues
points to negative/positive change in health status or pattern.
29
Clustering Cues
determine relatedness of facts and patterns
30
Plan
Deliberate, systematic phase where nurse forms client's plan of care and refers to assessment and diagnosis to formulate goals and design interventions
31
Nursing Interventions
treatment nurse performs to enhance patient outcomes and achieve goals
32
Types of Planning
Initial, ongoing, discharge
33
Intial planning
initial plan of care developed at admission assessment
34
Ongoing Planning
Done by all nurses who work w/ client to be updated and evaluate client's response to care. Done at begining of shift
35
Discharge Planning
anticipating and planning needs after discharge, essential to comprehensive care. Begins at first contact and ongoing
36
Types of Care Plans
Informal, Formal, Standardized, and Individualized
37
Informal Nursing Care plan
plan that exists in nurse's mind
38
Formal Nursing Care Plan
written/computerized guide that organizes info.
39
Standardized Care Plan
formal plan that specifies nursing care for groups of clients with common needs
40
Individualized Care Plan
tailored to meet unique needs of specific client
41
Care Plans
actions nurses must take to address client's nursing diagnoses, produce desired outcomes, integrate independent/dependent nursing fuctions
42
Care Plans- Nurse needs to..
ID what problems need to be individualized or standardized, individualize desired outcomes
43
Documents in Plan of Care
describe routine care needed to meet basic needs, client's nursing diagnosis, specify nursing responsibilities in carrying out medical diagnosis
44
Planning Process
Setting priorities, est. client goals, selecting nursing interventions, writing individualized nursing interventions on care plans
45
Setting Priorities
Planning- preferential sequence of action. Based on client's responses, problems, and therapies
46
Establishing Client Goals
Planning- broad statements that are: observable/measurable responses, realistic, time-specific, and client centered
47
Long-term Goals
guide planning for discharge to long-term agencies/home care. weeks to months
48
Short-term Goals
short-time health care. hours to days
49
Goal Statements
Subject (client), Verb (action performed/directly observable behaviors), Conditions/modifiers (When, what, how), and Criterion of goal (time, speed, distance, etc.)
50
Focus of Nursing Interventiosn
Achieve goal via eliminating/reducing etiology and treat S/S
51
Types of Nursing Interventions
Independent, Dependent, Collaborative
52
Delegation
transfer of responsibility for performing task while retaining responsibility of outcome
53
Assignment
downward/lateral transfer of both task responsibility and accountablility
54
Implementation Definition
nurse performs nursing interventions written from planning phase. Doing/documenting specific nursing actions need to carry out intervention
55
Process of Implementation
reassessing client, determining nurse's need for assistance, implementing nursing interventions, supervising delegated care, documenting
56
Reassessing Patient
Implementation-intervention still needed? reset priorities?
57
Need for assisstance
Implementation- does the nurse need help to perform activity safely and efficiently
58
Implement nursing interventions
Implementation- Provide Patient teaching (what, purpose, sensations, participation, outcomes)
59
Supervising Delegated Care
Implementation- responsible for client's overall care and must ensure activities have been implemented correctly
60
Document Nursing Activities
Implementation- completes implementation phase via recording interventions and client's response
61
Evaluation
planned, ongoing, purposeful activity to determine progress towards goal achievement and effectiveness of nursing plan of care
62
Result of Evaluation
nursing interventions are terminated, continued, or changed
63
Types of Evaluation
continuous, specific interval, and discharge
64
Continuous Evaluation
during and immediately after implementation of nursing intervention- can be modified
65
Specific Interval Evaluation
shows extent of progress toward goal
66
Discharge evaluation
status of goal achievement and clients self-care abilities and follow up care
67
Process of Evaluation
Collecting data related to desired outcomes, comparing data with outcomes, relating nursing activities to outcomes, drawing conclusions about problem status, and continuing/modifying/terminating nursing care plan
68
Thress Conclusions of evaluation
Goal was met- client's response= desired outcomes. Goal was partially met- short-term goal achieved but long-term wasn't. Or desired outcome only partially reached Goal was not met
69
Evaluation Statement
Conclusion (met, partially met, not met) and supporting data (client's responses)
70
Critical Thinking Definition
a discipline specific, reflective reasoning process that guides a nurse in generating implementing, and evaluating approaches for dealing with client care and professional concerns

Test II N121 (2 decks)

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