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Nursing 101 > Test 2 > Flashcards

Test 2 Flashcards

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1
Q

What does QS EN stand for? What does it provide? And what competencies does it Portray?

A

Quality and safety education in nursing provides patient centered care with knowledge, skill, and attitude competencies.

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2
Q

Define clinical reasoning.

A

Ways of thinking about patient care issues.

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3
Q

Define clinical judgment.

A

Result of critical thinking.

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4
Q

Provide a brief description of the nursing process steps.

A

Assessing: systematically collect patient data.

Diagnosing: clearly identify patient strengths and actual and potential problems.

Planning: develop holistic plan of individualized care that specifies the desired patient goals and related outcomes and the nursing interventions most likely to assist the patient to meet as expected outcomes.

Implementing: execute the plan of care.

Evaluating: evaluate the effectiveness of the plan of care in terms of patient goal achievement.

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5
Q

What does NANDA stand for and its purpose?

A

North American nursing diagnosis association

Classifies phenomena of concern to nurses. Provides diagnosis.

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6
Q

What is NIC and NOC?

A

NIC-nursing interventions classification: identify, label, validate, and classify actions nurses perform. (Indirect and direct interventions)

NOC-nursing sensitive outcomes classification:
Identify, label, validate, and classify nursing sensitive patient outcomes and indicators

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7
Q

What are the characteristics of the nursing process?

A

Systematic, dynamic, interpersonal, outcome oriented, universal in nursing situation.

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8
Q

What are critical thinking indicators?

A

Descriptions of behaviors that demonstrate knowledge, characteristics, and skills that promote critical thinking in clinical practice.

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9
Q

What are the blended competencies, and the need for those?

A

Cognitive, interpersonal, ethical/legal and technical.

To successfully manage patient care scientifically, holistically, and creatively.

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10
Q

What is evidence based practice and evidence based guidelines?

A

EBP-problem-solving approach using best evidence with clinical expertise and patient values.

Guide-recommended best practices of disabilities, symptoms, disease treatment from studies. Includes legality, ANA, and facilities reg

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11
Q

Explain each of the blended competencies.

A

Cognitive- focused thinking using critical thinking

Technical- manual skill

Interpersonal- promoting human dignity and respect. Person centered care.

Ethical/legal- securing pt well being

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12
Q

What is the purpose of a concept map?

A

Approach to plan of care holistically, it is a diagramed sequence of the nursing process.

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13
Q

What are the 4 types of assessment?

A

Initial-upon admit, complete database, baseline

Focused-RN gathers specific data pertaining to existing problem

Emergency-ID life threatening issues

Time lapsed-compare current to baseline

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14
Q

What are 3 types of collected data for assessment?

A

Subjective- info from affected person (cannot be verified) such as pain

Objective-observable, literature. Seen, heard, felt, smelled.

Diagnostic- nursing hx/ physical asses

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15
Q

What are some key info points obtained in assessment?

A

Data collection (sub/obj/diag)

ID cues/make inferences

Validate data

Cluster related data/iD patterns

Report/record data

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16
Q

What are some sources of data collection?

A 
PRIMARY-patient
Family
Record
Other healthcare provider (med hx, consults, tests)
Literature
Nurse hx, pt interview
Physical assessment
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17
Q

What is charting by exception?(CBE)

A

Significant findings or exceptions to well-defined standards documented in narrative notes.

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18
Q

What is a collaborative pathway?

A

Case management plan developed for patient population with designated diagnosis/procedure. Includes outcomes, interventions

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19
Q

What is focus charting?

A

A list incorporating a patient focus such as strength, problem, or need. Concerns behaviors, etc
Focus on pt priority instead of problem list or diagnosis’s

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20
Q

Define “meaningful use” in documentation.

A

Use of certified electronic health record technology with financial incentive for Medicare and Medicaid.

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21
Q

What is PIE charting?

A

Documentation system with care plan incorporated into progress notes. Problem, intervention, evaluation. (Evaluated each shift.)

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22
Q

What is the soap format?

A

A method of charting narrative notes organizes according to subjective, objective, assessment, and plan.

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23
Q

When should the nurse document?

A 
Admission/transfer/ d/c
Procedure performed
Post op/post proc 
Commun with dr
Status changes
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24
Q

What are narrative notes? And describe.

A

Progress notes written by nurses in a source oriented record.
Source oriented records are from paper. These are for medical personnel.

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25
What is the difference between the pie and soap method of documentation?
Pie is nursing origin. Care plan included. Soap originated from medical record and requires formal care plan.
26
What is nursing informatics?
Specialty integrating nursing science, computer science, and information science to manage or communicate data
27
What are 10 non verbal methods of communication?
Touch, eye contact, facial expressions, posture, gait, gestures, general physical appearance, mode of dress/groom, sounds, and silence.
28
What is a collaborative pathway?
Detailed case Management plan-pop w/ desig diag/Proc.
29
The flow sheet includes? Whereas the graphic record includes?
Flow-Graphic record of abbr pt cond. (v/s)_Quick doc. Daily pt routine care Graphic-specifics on pt characteristics
30
What is POMR?
Doc sys according to pt specific health prob.(database, prob list, care plan, and progress notes)
31
What is the purpose of acuity records?
Ranking pts from high to low based on condition
32
What are the ANA guides for effective documentation?
Accessible, accurate, relevant, consistent, audit able clear concise, and complete, legible/readable, thoughtful, timely, contemporaneous, and sequential, reflective of the nursing, retrievable on a permanent basis.
33
What is the agent that initiates a response of the nervous system?
Stimulus
34
What is the channel in communication?
Medium selected to convey a message
35
What are the variable characteristics of group communication.
Power: sources of power used with consideration of those w/o power Leadership Respon Decision Making Patterns of Interaction:members support/critique each other Cohesiveness: trusting/cooperative Group Id: value aims
36
What are the three phases of the helping relationship?
Orientation:ID, make goals, duration, etc. Working:pt actively participates, cooperate, express feelings Termination:ID accomplished goals/progress, verbalize termination feelings
37
What is the NANDA diagnosis definition?
A nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems or life processes. Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA-I).
38
What are 3 types of diagnoses and differentiate.
Medical dx: MD prescribed-describes dz or syndrome. Nursing dx: describes pt response to problems, health or illness. Collaborative dx:md and rn prescribed, complications
39
What are the 5 ANA competencies of the RN in diagnosing?
``` 1 derives dx from assessment data 2 validates 3 ID's actual or potential risks 4 uses approved classification to further ID diag 5 documents ```
40
What are the 2 focus's of the nursing diagnosis?
1 what creates the need for nurse | 2 pt response to health problem/intervention
41
What are some key factors of clinical reasoning when formulating a diagnosis?
``` Recognizing significant data Recognizing patterns Cues or clusters ID strengths/problems Reaching conclusions ```
42
The nurse reaches one of four identified diagnoses. What are those, explain.
No problem-reinforce wellness/health promo Poss problem-collect more data Actual problem-begin plan, implement, eval Clinical (non-nurse)-consult w/ appropriate health care Personnel
43
What are the 5 types of nursing dx?
1 Actual-valid problem w/ defining character 2 Risk-clinical judge of vulnerability (exp. elderly-fall risk) 3 Possible-suspected problem (need more data) 4 Wellness-pt transform from well to higher well, desires higher well 5 Syndrome-cluster of actual/risk nurse dx that are predicted from situation or event. (PTSD)
44
What is the appropriate NANDA approved nurse dx format? Define each.
``` (PES) Problem -related to- etiology (related factors/cause) -as evidenced by- (Signs/symptoms)Defining characteristics ```
45
What are the 4 components to the NANDA dx?
Label Definition Defining characteristics Related factors
46
What are 3 different types of planning?
Initial-admission Ongoing-carried out by RN/cont updating/specifics D/C-teaching/plan home care
47
During the outcome identification and planning steps of the nursing process, the nurse works in partnership with the patient and family to:
Establish priorities ID/write pt outcomes Select evidenced based nursing interventions Communicate the plan of care
48
What the 4 categories of outcomes?
Cognitive-increased pt knowledge Psychomotor- pt achieves new goal Affective-changes in pt values or belief/attitudes Physiological-pt returns to a level of functioning that prev. Obtained.
49
When writing pt centered measurable outcomes, what must be included?
Subject-pt (or part of pt) verb- action taken by pt Conditions-Circumstances by which outcome is to be achieved Performance criteria-describe in observable measurable terms the expected pt behaviors Target time-specifies when pt is able to achieve outcome (SMART-specific, measurable, attainable, realistic, time frame)
50
For actual nursing diagnoses, interventions seek to:
Reduce or eliminate contributing factors of the diagnosis Promote higher-level wellness Monitor and evaluate status
51
For risk nursing diagnoses, interventions seek to:
Reduce or eliminate risk factors Prevent the problem Monitor and evaluate status
52
For possible nursing diagnoses, interventions seek to:
Collect additional data to rule out or confirm the diagnosis.
53
For collaborative problems, interventions seek to
Monitor for changes in status Manage changes in status with nurse-prescribed and physician-prescribed interventions Evaluate response
54
What are 3 types of nursing interventions?
nursing initiated Healthcare provider prescribed Collaborative
55
What skills are used when implementing the plan of care?
``` Reassessing Clarifying Organizing Anticipating Promoting self care Assisting pts to meet health outcomes Preventing errors ```
56
What are roles of the RN vs the LPN in the nursing process?
RN-assess/analyze/diag/eval LPN-collect data/implement
57
What are the variables that can effect outcome achievement?
Patient (decline) RN (ethical, forgets) Healthcare system (staffing, supplies)
58
Diff criteria vs standards
Criteria-measurable, specified behavior | Standards-levels
59
Summarize the evaluation portion of the nursing process.
- Measure how well the pt has achieved desired outcome - ID factors contributing to the pt's success or failure. - modify the plan of care, if indicated
60
Summarize the assessment portion of the nursing process.
- Prepare for data collection - collect data - iD cues and make inferences - validate data - clustering related data and ID patterns - report/record
61
Summarize the diagnosing portion of the nursing process.
- interpret and analyze pt data - ID pt strengths and health problems - formulate and validate nursing dx - detect and refer signs and symps that may indicate a problem beyond the nurses experience
62
Summarize the Outcome ID/Planning portion of the nursing process.
- establish priorities - ID expected pt outcomes - select evidence based nursing interventions - commune the plan of care
63
Summarize the Implementing portion of the nursing process.
- carry out the plan - cont data collect and modify the plan of care prn - document care

Nursing 101 (5 decks)

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