Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Health safety n104 > Nursing process, documentation and reporting > Flashcards

Nursing process, documentation and reporting Flashcards

1
Q

Five steps of nursing process

A 
Assessment
Diagnosis
Planning
Implementation
Evaluation

ADPIE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Assessment

A

Collection, validation and communication of patient data.

Nursing history
Review patient record
Consult with Other professionals
Initial interview

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Diagnosis

A

Analysis of data to identify patient strengths and health probs that independent nursing intervention can prevent or resolve.

Formulate and validate diagnoses
Prioritized list of nursing diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Planning (and outcome identification)

A
  • expected patient outcomes to prevent, reduce or resolve problems
  • Develop nursing interventions
  • Setting goals
  • develop care plan
  • Communicate plan of nursing care

Identify expected outcomes, develop care plan

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Implementation

A
  • Carry out plan
  • Continue data Collection and modify the plan of care as needed
  • Document care
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Evaluate

A

Measure outcomes
Revise plan if needed
Measure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

6 phases of Assessment

A

1- collecting data
2- identifying cues and making inferences
3- validating (verifying) data
4- clustering related data
5- identifying patterns/ testing first impressions
6- reporting and recording data

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Clustering data according to functional health patterns (Gordon)
What are they? (10)

A

1- health perception, 2- nutrition,
3- elimination, 4- cognitive,
5- sleep, 6- self perception,
7- role/ relationship, 8- sexuality/ reproductive,
9- coping/ stress tolerance, 10- values/ belief

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Clustering data according to Human needs (Maslow)

5

A 
1-Physiologic/ survival
2- safety/ security
3- love/ belonging
4- self esteem
5- self actualization (grow, change)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

NANDA

A

Nursing dx system

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

4 major care plan components

A 
EASE
Expected outcomes
Actual and at risk problems
Specific interventions
Evaluate/ progress notes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

A difference between RN and Lpn

A

RN - assessment

LPN- data collection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

PES method
Aka PRS method
What do initials stand for?

A

PES: Problem, Etiology , signs and symptoms
PRS: Problem,Related factors, s/sx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is an example of a PES method?

A

Impaired communication related to Language barrier as evidenced by speaking and understanding only Spanish.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

5 rights of delegation

A 
Right task 
Right person
Right situation
Right communication (specific)
Right evaluation (rn evals patient’s response and workers performance)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

5 components of outcome statement

A 
1- subject: patient, parent..
2- verb: action needed to meet outcome
3-condition: under what circumstances?
4- performance criteria: how well?
5- target time
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

SOAP documentation

A

S- Subjective- what patient says
O—objective- measurable, observable
A— assessment- statement of the problem. Interpretation or conclusions
P- plan-

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Can also use SOAP-IER

What does the IER stand for?

A

I- interventions
E- evaluation- response to tx
R- revision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

PIE documentation

A

P- problem
I- intervention
E- evaluation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Focus charting

Uses DAR

A

D- data (eg- pain scale 8)
A- action (eg gave morphine)
R- response (eg pain scale 3)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Kardex

A

Patient data -

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

SBAR

A

Situation
Background
Assessment
Recommendation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which step in the nsg process does a nurse use when analyzing data to determine strengths?

A

Diagnosing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q 
Difference between:
focused assessment
Initial assessment
Emergency assess
Time lapsed assess
A
  • Focused- gather data about condition already diagnosed
  • initial- shortly after admission
  • emergency- crisis
  • time lapsed- compares current status to baseline data
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Nursing process is dynamic, systematic, interpersonal and universally applicable.
What do those words mean in relation to the nursing process?

A

Dynamic means much interaction and overlapping of the steps.
Systematic -ordered sequence of activities.
Interpersonal -human being at the heart of nursing.
Universally Applicable -it is a framework for all nursing activities

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Concept mapping

A

Instructional strategy that requires a learners to identify, graphically display, And link key concepts.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Which group legitimize the steps of the nursing process in 1973 by developing standards of practice to guide nursing practice?

A

American nurses Association Congress for nursing practice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

A list of nursing activities in the order they would most likely occur during the nursing process:

A

Establishing the database,
interpreting and analyzing patient data,
establishing priorities,
carrying out the plan of care,
measuring how well the patient has achieved desired outcomes,
modifying the plan of care if indicated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

steps of the scientific problem-solving process

A 
Problem identification, 
data collection, 
hypothesis formulation,
Plan of action, 
hypothesis testing, 
interpretation of results, 
evaluation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Minimum data set

A

Specifies info that must be collected for every patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Assessment interview phases: (4)

A

1- preparatory phase- nurse prepares patient and environment for interview
2- introduction- sets tone
3- working phase- collecting subjective data
4- termination is the conclusion of interview

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Gordon’s Functional health patterns model

A

1-Data is collected regarding the health perception and health management of the patient
2. Perception of the major roles and responsibilities in the patient’s life is explored
3- Elimination, activity, sleep, and sexuality are components of the assessment and data collection

33
Q

Objective data

A

Data plan based on facts and observations.

34
Q

Subjective data

A

Based on emotions and feelings of the patient

35
Q

Purposes of nursing diagnosis:

4

A

1- to identify how individual, family or community responds to actual or potential health and life processes
2- identify factors that cause or contribute to health problems (etiologies)
3-identify resources that can be drawn on to prevent or resolve problems
4-serve as a basis to select nursing interventions to achieve outcomes for which the nurse is accountable

36
Q

If a nursing diagnosis of “deficient knowledge, what goal must be included?

A

“Client will acquire knowledge about “

37
Q

What does a 3 part nursing diagnosis consist of?

A

Data analysis,
Problem identification,
Formulation of nursing diagnosis

I.e. - “nursing diagnosis” related to “etiology” as evidenced by “defining characteristic”

38
Q

What are the 4 types of nursing dx?

A

1- actual
2- wellness or health promotion
3- risk
4- syndrome

39
Q

Actual nursing dx

A

Identifies current health problem

-such as inadequate airway clearance

40
Q

Wellness or health promotion nursing dx

A

Identifies a patients readiness to transition to a higher wellness level-
- such as readiness for enhanced self care to increase cardiac output

41
Q

Risk diagnosis

A

Identifies when a patient could be at risk for additional health problems
- such as infection

42
Q

Syndrome diagnosis

A

Determines symptoms based on certain situations
Such as post trauma syndrome or relocation stress syndrome
Uses at least 2 nursing dx.

43
Q

Nursing history

What questions to ask about chief complaint?

A

Onset? (When? Gradual or sudden?)
Precipitating factor? (what were you doing?)
Description? (How would you describe it?)
Location?(where is discomfort and does it radiate?)
Duration?
Timing? (Continuous, intermittent?)
Frequency?
Intensity? (0-10)
Associated symptoms?
Factors that relieve or worsen?

44
Q

Common problems related to assessment

A

Omitting data,
using inappropriate or in adequate assessment tools,
failure to update the initial assessment

45
Q

Name 5 types of nursing diagnoses (excelsior study guide)

A 
Actual
risk, 
possible, 
wellness (readiness for enhanced knowledge)
syndrome
46
Q

Outcomes identification and planning (standard 3 and 4 of ANA standards of nursing practice)

A

Identify expected outcomes

And develop care plan

47
Q

Name four different guidelines/ standards to follow when Developing a plan of care

A
  1. ANA standards of professional nursing practice
  2. Academy of medical surgical nurses Scope and standards of medical surgical nursing practice
  3. QSEN Quality and safety in nursing education pre-licensure competencies
  4. Clinical guidelines
48
Q

3 different Oral reporting acronyms

A

Cuban- Confidential, Uninterrupted, Brief , Accurate, Named

SBAR-Situation, background, assessment (action), recommendation

PACE-patient/problem, assessment/action, continuing/changes, evaluation

49
Q

Phases of therapeutic Relationship

A

Pre-interaction,
orientation,
working,
termination

50
Q

Name 4 nursing diagnoses that address therapeutic communication problems

A

Readiness for enhanced communication,

impaired verbal communication,

impaired social interaction,

ineffective health maintenance

51
Q

Name six nursing diagnoses that address stress and anxiety

A

Anxiety,

ineffective coping,

ineffective denial,

defensive coping,

compromised family coping,

decisional conflict

52
Q

Name 3 Nursing diagnoses that address teaching and learning

A

Readiness for enhanced coping,

ineffective health maintenance,

readiness for enhanced health management

53
Q

List some factors that would be assessed in identifying a therapeutic communication problem

A 
Gender, age, 
language barriers,
developmental delays, CNS injury,
loose fitting dentures, cultural/spiritual,
noise level, presence of support system
54
Q

List some factors that would be assessed in use of stress and adaptation problems

A

Physiological signs (increased heart rate, diaphoresis, dilated pupils, dry mouth)
inability to focus, reporting feelings of anxiety,
decreased attention span,
levels of anxiety (mild- moderate -severe -panic)

55
Q

List some factors that could be assessed for a need for patient teaching

A 
Motivation, readiness to learn, communication barriers, 
mental illness,
learning disabilities, 
developmental stage, 
health literacy 
reading literacy
56
Q

Interventions to implement for a diagnosis of a problem with therapeutic communication

A

Establish trust,
use active listening,
therapeutic communication techniques,
provide alternate methods of communication, quiet private space

57
Q

Interventions to implement for a diagnosis that has to do with patient teaching

A

Use age appropriate communication techniques,

structure environment to promote learning,
use tools to support cognitive, psychomotor and affective learning -such as audio visual, demonstration and return demonstration

58
Q

Interventions to implement for diagnoses that have to do with stress and adaptation

A

Promote effective stress management

Involve patient in decision making

Encourage patient to express feelings

Use pictures or toys for kids

59
Q

Name two nursing diagnoses that address health promotion and maintenance

A

Sedentary lifestyle (related to lack of motivation as evidenced by choosing a daily routine lacking in physical exercise)

Ineffective health maintenance

60
Q

List 3 nursing diagnoses that would pertain to alterations in vital signs.

A

Ineffective peripheral tissue perfusion

ineffective breathing pattern (Related to pain as evidenced by shallow respirations)

Ineffective Thermoregulation (related to prolonged exposure to sub freezing temperatures as evidenced by temperature of 94.2°F)

61
Q

Factors to assess related to infection

A 
Developmental stage,
Illness, 
tobacco use, substance abuse,
chronic disease, medications, 
signs of infection

Lab data

62
Q

Focused assessment related to skin integrity

A

Braden scale risk assessment for a pressure ulcer development,

age, physical condition,
hydration and nutrition,
circulation, mobility, hygiene,

wound characteristics,
pressure ulcer staging
Lab data

63
Q

How to assess readiness to learn for:
—Infection prevention and control

—altered skin integrity

A

Determine knowledge of infection control measures in the home.

Verify patient’s understanding of wound care, treatment and prevention

64
Q

Interventions to Implement for wound care

A

Provide high-protein foods,
wound care as ordered,
applying heat and cold therapy, obtaining wound culture,
performing sterile irrigation

65
Q

Difference between standing orders and protocols

A

Standing Order: treatments you can perform before contacting the physician for permission.

Protocol: Standard that includes general and specific principles for managing certain patient conditions.

66
Q

What should nurse do when patient has Achieved each expected outcome?

A

Terminated plan of care. Patient has met goals

67
Q

What is one of the main focuses of the Evaluation phase?

A

Evaluating the patients goal/outcome achievement

68
Q

A type of evaluation that focuses on the environment that care is provided

A

Structure evaluation

Focuses on environment, physical facilities and equipment. Organizational policies and procedures

69
Q

A type of evaluation of nursing care and patient goals while the patient is receiving care

A

Concurrent evaluation

70
Q

What type of charting is the SOAP format?

A

Problem oriented

71
Q

What type of documentation method does each healthcare group keep data on at separate forms?

A

Source oriented

72
Q

What is a problem with Source oriented charting?

A

Data is fragmented because each healthcare group uses a separate place to document

73
Q

What is an advantage to source oriented documentation?

A

Each discipline can easily find and chart pertinent data

74
Q

According to the 2005 JCAHO requirements, how long after admission does a nurse have to complete px assessment and have documented history and physical in chart.

A

24 hours

75
Q

In a nursing diagnosis, what etiology can be used if there are too many etiologies to list or if too complex to list in brief phrase?

A

Related to complex factors.

76
Q

When should verifying data be done in nursing process?

A

At the end of assessment / interview.

77
Q

What are 3 phases of diagnostic process?

A

Data analysis

Identification of clients health problems, health risks and strengths.

Formulation of diagnosis

78
Q

Best places to assess for skin pallor

A

Soles of feet
Oral mucous membranes
Conjunctiva of eye

79
Q

Formula for drip rate

Drops per min

A

(volume ✖️drip factor)➗time in minutes

Health safety n104 (8 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions