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Nursing 130 > Unit 8 > Flashcards

Unit 8 Flashcards

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0
Q

What is ADOPIE?

A 
Assess the patient
Diagnois
Outcome
Planning
Implementation
Evluation
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1
Q

What is the nursing Process?

A

Defined as a systematic problem-solving approach toward giving individualized nursing care

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2
Q

What is assessment?

A

refers to evaluation or appraisal of a patients health state. During this time subjective and objective data is collected,

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3
Q

What is primary Source?

A

The patient is the main source of information in the assessment

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4
Q

What consist of secondary data?

A

Family members, significant othes, other helathcare professionals, health records, and literature review.

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5
Q

When does observation begin?

A

First encounter and is ongoing.

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6
Q

What does it mean to diagnose?

A

To analyze assessment information and derive meaning from this analysis.

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7
Q

What is a nursing diagnosis according to NANDA?

A

a clinical judgement about individuals,family or community responses to actual or potential health problems/life processess.

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8
Q

What is the diagnostic reasoning process?

A

used to make accurate clinical diagnoses about patient problems.

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9
Q

What is Diagnostic reasoning?

A

Process of gathering and clustering data to draw inferenes and propose diagnoses.

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10
Q

5 steps of diagnostic reasoning?

A 
Organizing the existence of cues
generating possible diagnoses
comparing cues to possible diagnoses
conducting a focused data collection
validating diagnoses
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11
Q

According to NANDA what is outcome identification?

A

To formulate and document measurable, realistic, patient-focused goals.

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12
Q

True or False:

JCO requires a written plan of care for each patient.

A

True

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13
Q

What type of written form is premitted by JCO to be acceptable to give to the patient?

A 
Handwritten notes
electronic records
preprinted forms
care paths or maps
individualized preprinted plans of care
standards of practice
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14
Q

What is Implementation?

A

This is the action phase of the nursing process. Actually initiation of the plan, evaluation of response to the plan, and recording of nursing actions and patient response to these actions.

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15
Q

What does the evaluation phase include within the nursing process?

A

Refers to rating, grading, and judging to determine why the patient plan of care was a success or failure.

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16
Q

What is Critical Thinking?

A

Self-guided, self-disciplined thinking that attempts to reason at the highest level of quality in a fair-minded way.

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17
Q

What is active listening?

A

Implies that nurses are responsive to the cues that patients are sending

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18
Q

What is reflection?

A

those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understanding.

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19
Q

What is a human patient simulator?

A

A life-sized mannequinn with a sophisticated computer interface, presents you with clinical scenarios that evolve based on decisions that you make.

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20
Q

What is a novice?

A

learners use rules to guide practice.

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21
Q

What is an advance beginners?

A

Nurses learn to consider more facts and complex rules

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22
Q

What is competence?

A

Nurses gain this aspect through experience

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23
Q

What is assessment?

A

Is the collection of data for nursing purposes.

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24
What is focus Assesment
Collects data about a problem that has alsready been identifeid.
25
Time lapse assessment?
takes place after the intial assessment to evaluate any changes in the patients health.
26
Emergency Assessment?
life-threatening situation in which the preservation of life is the top priority.
27
Observation involves using which senses?
Sense of smell, touch, hearing, seeing, and rarely tasting
28
What is a physical examination techniques?
Data collected method that uses the senses of sight, hearing, smell, and to detect health probelms.
29
What 4 techniques are used during a physical examination?
Inspection, palpation, percussion, and auscultation.
30
What is Inspection
Visual examination of the patient that is done in a methodical and deliberate manner
31
What is palpation?
The specialized use of touch for data collection that augments the inspection process.
32
What is percussion?
Technique in which one or both hands are used to strike the body surface in a precise manner to produce a sound called a percussion note
33
What is auscultation?
listening to the body sounds with a stethoscope place on the body surface to amplify normal and abnormal sounds.
34
What is subjective data?
Known as symptoms which includes a patients feelings and statments about his or her health problems
35
What is objective data?
Known as signs, are observable, perceptible, and measurable
36
What are the two type of sources that can be used for data?
Primary and Secondary. Primary is from the patients. Secondary source are from other places i.e family and other healthcare facilities.
37
What is validation?
Referred to as double-checking the information at hand.
38
What is nursing diagnosis?
Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
39
What is taxonomy?
Classification system, to provide a structure for nursing practice.
40
What is a medical diagnosis?
Disease or pathology of specific organs or body systems
41
What is a collaborative health problem?
Refers to actual or potential physiologic complication that can result from disease, trauma, treatment, or diagnostic studies for which nurses intervene in collaboration with personnel of other disciplines
42
What are related Factors?
describe the conditions, circustances or etiologies that contribute to the problem.
43
What does the term risk factor mean?
describe clinical cues in risk nursing diagnoses and are not used for actual nursing diagnoses.
44
What is premature closure?
Selecting a diagnosis before analyzing pertinent information.
45
What is an actual nursing diagnosis?
Describes a human response to health problem that is being manifested. It is written as a three part statement: Diagnostic Label, defining characteristics, and related factors
46
hat is an "risk nursing diagnosis"?
describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
47
What is a possible Nursing diagnosis?
When not enough evidence supports the problem, but the nurse thinks that it is highly probable and wants to collect more information.
48
What is Outcome Identification?
The formulation of goals and measurable outcomes that provide the basis for evaluating nursing diagnoses.
49
What is a qualifier?
A description of the parameter for achieving the outcome
50
Outcome criteria often referred to as S.M.A.R.T stands for what?
Specific, Measurable, Attainable, Reasonable, Time Specific
51
What Phase is Planning within the Nurse ?
Planning is the fourth phase of the nursing process, refers to the development of nursing strategies designed to amerliorate patient problems
52
What is the purpose of Planning?
``` Direct patient care activities Promote continuity of care Focus charting requirements allow for delegation of specific activites Planning nursing interventions writing the patient plan of care ```
53
What are Nursing Interventions?
Any treatment, based upon clinical judgement and knowledge, that nurse performs to enhance patients outcomes
54
What is scientific rationale in the Nursing intervention?
IS the justification or reason for carrying out the intervention
55
What is the evaluation within the nursing Intervention?
A written statement that determines the patients status in relation to the outcome criteria at a particular time
56
What is a critical pathway?
Are the commonly used standard guidelines for patient care in many hospitals. This is acceptable by Joint Commission.
57
What is a Variance?
Deviation occurs in the path that alters an expected outcome or the date of discharge.
58
What is Implementation within the Nursing Process?
Nursing care is provided.
59
What are possible advantages of NIC?
Creation of standard language that promotes better understanding and communication of nursing interventions Expansion of knowledge about similarities and differences across nursing diagnoses Exploration of nursing care information systems Assistance in determine cost of services that nurses provide Demonstration of the impact nurses have within the health-care system
60
What 3 Categories does Nursing intervention fall within?
Cognitive skills, Interpersonal skills, and technical skills
61
when should cognitive intervention be used?
it would be used during educational interventions to teach patients
62
what is supervisory intervention?
insuring that other members of the nursing team cary out specific aspects of the plan of care and that those involved with the patient or family show return demonstration of skills?
63
what is standard of care?
authoritative statements made by nursing organizations, external review boards or heath care institutions that describe the responsibilities of the nursing profession against which its practitioners are healed accountable
64
what are the 3 types of nursing evaluations within the nursing process?
structure eval, process eval, outcome eval
65
what is structure evaluation?
it focuses on the attrubutes of the setting or surrounding where health care is provided
66
What is Process evaluation?
Focuses on the nurses performance and whether the nursing care provided was appropriate and competent
67
what is outcome evaluation?
it focuses on the patient and the patients function, is currently recieving a great deal of emphasis
68
what is a nursing monitor also referred to as nursing audit?
any review completed by a nurse of patients care or records to evaluation weather established standards were met
69
what is joint commission?
external review board that establishes standards for institutions to ensure that the institution functions with in specified guide lines
70
what is peer reivew?
evaluation and judgment of a nurses performance by other nurses
71
what is quality improvement program?
mechanisms for health care organizations to assess and improve care
72
Client comes enters the healthcare facility and is evaluated for their health status, identifies functional problems. This is referred to as what?
Admission assesment
73
What is Wellness Nursing Diagnosis?
The potential to achieve a higher level of wellness.
74
What are the various types of Nursing Care Plans?
``` Individual Plan of Care Standardized Generic Plan of Care Computer Generated Collaborative Care Plan Instructional Care plans ```
75
What are common errors in witing Nursing DX?
Identifying as a problem signs and symptoms of illness Identifying as a patient problem or etiology what cannot be changed Including medical diagnosis in diagnostic statement

Nursing 130 (8 decks)

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