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Fundamentals of Nursing > Nursing Process: AD > Flashcards

Nursing Process: AD Flashcards

1
Q

Nursing process is a _____, rational method of _______ and providing _______ nursing care.

A
  • Systematic
  • planning
  • individualized
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2
Q

A client may be an?

A
  • individual
  • family
  • community
  • group
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3
Q

Purpose of the Nursing Process:

  1. To identify a client’s ________
  2. To identify _____ or _______ health care problems or needs
  3. To establish ______ to meet the identified needs
  4. To deliver specific _______ to meet those needs.
A
  • health status
  • actual, potential
  • plans
  • nursing interventions
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4
Q

what are the characteristics of nursing process?

A
  • cyclic and dynamic nature
  • client centeredness
  • focus on problem solving
    -decision making
  • interpersonal collaborative style
  • universal applicability
  • use of critical thinking
  • use of clinical reasoning
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5
Q

what are the phases in the nursing process?

A

ADPIE
- assessment
- diagnosis (nursing diagnosis)
- planning
- implementation
- evaluation

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6
Q

it is the first step in the nursing process

A

assessment phase

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7
Q

it is the systematic and continuous collection, organization, validation, documentation of data or information

A

assessment phase

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8
Q

this phase is carried out during all phases of the nursing process

A

assessment phase

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9
Q

a characteristic where data from each phase provide input into the next phase. Findings from the evaluation phase feed back into assessment. Hence, the nursing process is a regularly repeated event or sequence of events that is continuously changing

A

cyclic and dynamic nature

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10
Q

a characteristic where the nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine the client’s habits, routines, and
needs.

A

client centeredness

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11
Q

a characteristic where mental activity in which a problem is identified (unsteady state)
and requires clarifying the nature of the problem and suggesting
possible solutions.

A

focus on problem solving

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12
Q

a characteristic where nurses can be highly creative in determining when and how to
use data to make decisions.

A

decision making

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13
Q

characteristic that requires the nurse to communicate directly and consistently with
clients and families to meet their needs.

A

interpersonal and collaborative style

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14
Q

characteristic that is used as a framework for nursing care in all types of health care settings, with clients of all age groups.

A

universal applicability

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15
Q

characteristic in which requires the nurse to think creatively, use reflection, and engage
in analytical thinking

A

use of critical thinking

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16
Q

characteristic by reflecting the nurse determines whether the outcome of care
was appropriate.

A

use of clinical reasoning

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17
Q

what are the 4 types of assessment?

A
  • initial assessment
  • problem-focused
  • emergency
  • time-lapsed reassessment
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18
Q

-performed within a specified time after admission to healthcare facility

A

initial assessment

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19
Q

-done to establish a complete database for problem identification, reference & future comparison.

A

initial assessment

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20
Q

approaches to assessment :
a) ________
b) ________
c) ________

A
  • Head-to-toe approach
  • Body systems approach
  • Combination approach
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21
Q

-performed to determine status of a specific problem identified in an earlier assessment
- example of a problem-focused assessment
- ______
- _____

A
  • problem-focused assessment
  • MIO
  • Self-care ability
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22
Q

-performed during physiologic or psychologic crisis of the
client

A
  • emergency assessment
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23
Q

-done several months after initial assessment to compare the client’s status to baseline data previously obtained.

A
  • time-lapsed reassessment
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24
Q

assessment involves the following:
* _______
* _______
* ________
* ________

A
  • Collecting data
  • Organizing data
  • Validating data
  • Documenting data
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25
Q
  • contains all the information about a client
  • referred to as the baseline information of the client
  • fundamental data in which the nurse builds client care.
A

Database

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26
Q

Database includes the following:
1. ________
2. ________
3. _______
4. ________

A
  1. nursing health history
  2. physical examination (ippa)
  3. laboratory & diagnostic test results
  4. material contributed by other health personnel
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27
Q

who is the primary source in collecting data?

A
  • client
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28
Q

who are the secondary source in collecting data?

A

● Support people (family members)
● Health care providers
● Client records
● Relevant literature
● All sources other than the client

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29
Q

what are the 2 types of data?

A
  • subjective
  • objective
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30
Q

______ it is referred to as _______ or covert data

● Data from client’s (and sometimes family’s) point of view.
● Includes feelings, perceptions, and concerns.
● Collected through _______.

A
  • subjective
  • Symptoms
  • interview
31
Q

_______ also called ______ or overt data.

● observable and measurable data obtained through _________ and laboratory and diagnostic testing.

A
  • Objective
  • signs
  • physical examination
32
Q

what are the 3 methods of collecting data?

A
  • interview
  • observation
  • physical examination
33
Q

type of interview that focuses on the profile of the client/health history

A
  • initial formal interview
34
Q

type of interview that informally taken during N-P interaction

A
  • on-going interview
35
Q

Collected information must be organized to
be useful.

A
  • organizing data
36
Q

through organizing data, data ________ & data _______ is a useful way to identify significant and related information.

> Actual/ Abnormal findings
Risk/ Related Factors
Strengths/ weaknesses

A
  • screening
  • clustering
37
Q

what are the 3 models or frameworks used in organizing data?

A
  1. Gordon’s 11 Functional Health Pattern Framework
  2. Orem’s Self-care Model
  3. Roy’s Adaptation Model
38
Q

The model describes the client’s need for adequate nutrition, normal elimination, and adequate rest to promote normal human functioning and development.

A
  • orem’s self-care model
39
Q

Outlines the data to be collected and classifies observable behavior into four categories:
physiological, self-concept, role function, and interdependence

A
  • roy’s adaptation model
40
Q

“Double-checking” or verifying data to confirm that it is accurate and factual

A
  • validating data
41
Q

Usually done when discrepancies occur in the data gathered in the interview and PE

A

validating data

42
Q

validating data ensures…
> ensures that assessment data is ______
> ensures that ______ & related _______ data agree
> ______ important data may be gathered
> _______ jumping to conclusions
> differentiates between ______ & ______

A
  • complete
  • objective, subjective
  • additional
  • avoid
  • cues, inferences
43
Q
  • Assessment data must be recorded and reported.
  • Accurate and complete recording of assessment data is essential
    for communicating information to health care team.
A

documenting data

44
Q

refers to the reasoning process

A

diagnosing

45
Q

statement or conclusion regarding the nature of a phenomenon

A

diagnosis

46
Q

standardized NANDA names for the diagnoses

A

diagnostic labels

47
Q

causal relationship between the problem & its related or risk factors

A

etiology

48
Q

recognizing the participation and contributions of nurses in the United States and Canada.

A

NANDA (North American Nursing Diagnosis Association)

49
Q

The purpose of NANDA International is to _____, _______, and promote a ________ of nursing diagnostic terminology of general use to professional nurses

A
  • define
  • refine
  • taxonomy
50
Q

_______ is a clinical judgment by the physician that determines a specific disease, condition or pathological state.

A
  • medical diagnosis
51
Q

_________ is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes.

A

nursing diagnosis

52
Q

it is a statement of the client’s problem which consists of the diagnostic label plus etiology.

A

nursing diagnosis

53
Q

what is the nursing diagnosis for these medical diagnosis
1. pneumonia
2. amputation
3. type 2 diabetes mellitus
4. post-op prostatectomy
5. cerebrovascular accident

A
  1. ineffective airway clearance
  2. disturbed body image
  3. risk for unstable blood glucose
  4. impaired urinary elimination
  5. self-care deficit: dressing
54
Q

Type of nursing dx that focuses on a client problem at the time of assessment

Ex. Ineffective Breathing Pattern and Anxiety

A

actual dx

55
Q

Type of nursing dx, problem does not exist but the presence of risk factors indicates that a problem is likely to develop if unattended.

Ex. Risk for Infection

A

risk dx

56
Q

Type of nursing dx which human responses to levels of wellness in an individual, family or community that have a readiness for enhancement .

Ex. Readiness for Enhanced Nutrition

A

wellness dx

57
Q

Making a nursing diagnosis is the scientific identification of the client’s needs. It requires:

(1) use of _____
(2) identification of ______ in the external & internal environment
(3) awareness of client’s ________ to stress

A
  • judgment
  • stresses
  • reaction
58
Q

what part statement consists of a NANDA label only.

A

one-part statement

59
Q

What are the 3 types of nursing diagnosis

A
  • actual dx
  • risk dx
  • wellness dx
60
Q

what format is used in the two-part statement

A

PE format (problem statement and etiology)

61
Q

describes the client’s response to an actual or potential health problem or wellness condition.

A

problem statement or diagnostic label

62
Q

the related cause or primary factors contributing to the problem. The two parts are joined by the words ________

A
  • etiology
  • related to
63
Q

what format used for three-part statement

A

PES format

64
Q

subjective and objective data and clinical manifestations.

  • Connects the two parts using as manifested by or evidenced by
A

signs and symptoms or defining characteristics

65
Q

This format can not be used in risk nsg. Dx

A

basic three-part statement

66
Q

process of designing an action plan through which lifestyle behaviors can be prevented, reduced or eliminated.

A

planning

67
Q

phase which involves decision making and problem solving.

A

planning

68
Q

End product of the planning phase is the _______

A

NURSING
CARE PLAN.

69
Q

3 types of planning

A
  • initial
  • ongoing
  • discharge
70
Q

developing a preliminary plan of care by the nurse who performs the admission assessment.

A

initial planning

71
Q

continuous updating of
client’s plan of care. Nurse can individualize the initial plan further.

A

ongoing planning

72
Q

Involves critical anticipation and planning for client’s needs after discharge.

A

discharge planning

73
Q
A

Fundamentals of Nursing (10 decks)

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