Nursing Process (4)
Way of thinking and acting based on the scientific method
Client centered
Think cognitively and critically
Use creativity
Use intuition
Framework upon which nursing care is based
Critical Thinking (4)
Directed, purposeful mental activity by which ideas are created and evaluated, plans are constructed and desired outcomes are decided; can occur in or out of the clinical setting
Priority (4)
Something taking precedence over other things at a particular time because of greater importance
Outcomes (4)
Results of actions
Clinical Judgement (4)
The outcome or results of clinical reasoning
Scientific method (4)
Step-by-step process used by scientists to solve problems
Clinical reasoning (4)
Critical thinking in the clinical setting
Cues (5)
Pieces of information that influence decisions
Data (5)
Pieces f information on a specific topic
Goal (5)
Broad idea of what is to be achieved through nursing intervention
Signs (5)
Abnormalities objectively verifiable by objective meand
Symptoms (5)
Data the patient says are occurring that are not verifiable by objective means
Etiologic factors (5)
Causes of the problem
Database (5)
All of the information gathered about a patient
Inferences (5)
Conclusions made based on observed data
Interview (5)
Verbal interaction with patient to obtain data
Subjective data (5)
Data obtained from the patient verbally
Objective data (5)
Data that can be measured (Obtained by the interviewer through the senses and hands-on physical examination)
Implementation (6)
Carrying out nursing interventions
Interventions (6)
Actions that come from collaborative care planning
Documentation (6)
Recording of pertinent data on the clinical record
Evaluation (6)
Assessment of effectiveness of nursing actions in meeting expected outcomes
Clinical pathway (6)
Step-by-step approach to the total care of the patient
Outcome-based quality improvement (6)
Manage the quality of performance
Nursing audit (6)
Examination of patient records to see if patient care meets accepted standards
Independent nursing action (6)
Nursing action based on nursing judgement that does not require an order
Dependent nursing action (6)
Action requiring a health care provider’s order
Interdependent action (6)
Actions involving more than one health care professional
Time-flexible (6)
Can be done at any time
Time-fixed (6)
Must be done at a set time
Problem solving steps (4)
- Define the problem clearly
- Consider all possible alternatives as solutions to the problem
- Consider the possible outcomes for each alternative
- Predict the likelihood of each outcome occurring
- Choose the alternative with the best chance of success that has the fewest undesirable outcomes
What would be an independent nursing action? (6)
Teaching about the side effects of a medication
Nursing diagnosis is a way of (5)
stating patient problems
Assessment consists of gathering information about patients and their _____ using _________. (6)
needs
a variety of methods
Assessment is an_____ process. (6)
ongoing
Defining characteristics are the ____ and ____ attached to a nursing diagnosis that indicate the data from which the diagnosis was derived. (6)
signs
symptoms
Etiologic factors are those that indicates the patient’s ____ status or risk of a _____ _____, the causative or related factors, and the specific ____ _____. (6)
health
problem developing
defining characteristics (signs and symptoms)
When nausea is expressed, it would be considered _____ data. (6)
subjective
In order to perform efficiently and to set priorities, sat the beginning of the shift, the nurse should perform a quick ___ for each assigned patient. (6)
assessment
NANDA nursing diagnoses may be actual or related to _____. (6)
a risk, syndrome or to promote wellness
Before you interview a patient, you should perform a ____. (6)
chart review
The nursing problems present for a patient are determined by _____ the assessment data. (6)
analyzing
Nursing care is delivered by considering the order of ____ of the patient’s needs or problems. (6)
priority
Expected outcome statements should be written so that they are easy to ____ whether or not they have been achieved. (6)
evaluate
When prioritizing nursing care, _____ always take precedence. (6)
physiologic needs for basic survival (ABC)
When analyzing the information gathered during assessment, you should look for ____ indicating deviation from the norm. (6)
cues
Sources of data used for the information of a patient database: (6)
Interviews Defining characteristics Physicians history and physical ancillary staff notes admission notes
Methods used to gather a patient database: (6)
- Interview
- Chart Review
- Physical Exam
5 Steps of the Nursing Process (4) - ANPIE
- Assessment - RN
- Nursing Diagnosis - RN
- Planning
- Implementation
- Evaluation
Assessment
Data collection - (facts)
Prioritize and organize
Validate (readback)
Document
Nursing Diagnosis
Identify the health status and problems of the patient
Planning
Get an outcome Determine goals and outcomes Decide on interventions to reach goals Promote wellness of patient Prevent/correct any problems Relieving any problems that exist
Implementation
Performing actions to make plan work
Delegate some tasks
Document
Evaluation
Check to see if plan worked (goals achieved)
Patient benefits from Nursing Process
Needs are being met
Nurse benefits from Nursing Process
Learn from each situation
Meets standards of practice
Continuity of care
Job satisfaction
