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Nurs 101 Lecture > Week 1 > Flashcards

Week 1 Flashcards

1
Q

What is the Nursing process

A

ADPIE

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2
Q

Assessment

A

Collect and analyze data

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3
Q

Medical diagnosis

A

Focuses on disease and pathology

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4
Q

Nursing diagnosis

A

Focuses on patient response to illness

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5
Q

How is data used

A

By other disciplines

For Nursing Care

To ensure clients receive
-proper care
-by qualified individuals
-at the correct time

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6
Q

Cana RN delegate assessment

A

No.

CNA and LPNs can collect data such as vital signs. However it is the RNs responsibility to assign those tasks, confirm accuracy of data, conduct interview and do physical assessment.

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7
Q

What are the types of data

A

Objective, subjective, primary, and secondary

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8
Q

Objective data

A

Data the nurse observes.

Data that comes from lab, etc.

Can be measured

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9
Q

Subjective data

A

What the patient reports

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10
Q

Primary data

A

Obtained directly from the patient or observed the patient.

Vitals.

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11
Q

Secondary data

A

From someone other than patient. Includes patient record.

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12
Q

Skills of the nursing assessment/how to obtain data

A

Observation

Physical assessment

Interviewing

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13
Q

Nursing interview

A

Structured communication

To gather subjective data

Can be done direct or nondirect

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14
Q

Directive interview

A

Closed ended. Nurse in charge

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15
Q

Nondirective interview

A

Open ended.

Patient in charge.

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16
Q

When to verify data

A

Subject and objective data conflict

Clients statement are inconsistent

Data is far out of normal range

Factors that impact accuracy are present

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17
Q

Documentation Guidelines

A

-do so soon as possible

-rarely use acronyms

-use patient’s own word when possible

-use concrete specific information

-document cues but not inferences

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18
Q

Diagnosis

A

Analyze and interpret the data

Draw conclusion

Very conclusion

Prioritize problems

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19
Q

Health problem

A

Disease or illness that requires intervention

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20
Q

Nursing Diagnosis

A

Health problem that nurse identifies, prevents, or treats independently.

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21
Q

Diagnostic reasoning

A

Use critical thinking to analyze and interpret data

Draw conclusions about health status

Verify problems with client

Record diagnostic statement

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22
Q

Prioritizing problem

A

Maslows hierarchy of needs guides priority for nurses. Multiple problems can be addressed at once.

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23
Q

Priority levels

A

High-life threatening

Med-may causes serious physical or emotional changes

Low-requires minimal nursing intervention

24
Q

Planning

A

Select standard care plan

Create individualized care plan

Identify outcomes and goals

25
Q

Initial planning

A

-Begins at first client contact

-Done shortly after initial assessment

-development of initial comprehensive care plan

26
Q

Ongoing planning

A

Changes made as client responds to care

27
Q

Discharge planning

A

-self care and continuity of care after discharge

-Begins with initial assessment

-Requires collaboration

28
Q

Process for writing individualized care plan

A

Make list of problems

Identify which problems can be addressed with standardized care plan

Individualize standard care plan

Include ADLs and basic care needs

Develop individualize care plans for the problems not addressed by standardized care plan

29
Q

Goals/outcome

A

Goals: Change in health status that we hope to achieve

Nursing sensitive outcomes: can be influenced by nursing interventions

30
Q

Long term goals

A

Achieved over week or more

31
Q

Short term goal

A

Few hours to few days

32
Q

Planning intervention

A

Review diagnosis and outcome

Select standardized intervention

Individualize to meet patient needs

33
Q

Nursing intervention classification

A

Has label, definition, and list of activities

Are linked to Nanda-1 diagnosis and NOV outcome labels

34
Q

Nursing orders

A

Date

Subject

Verb

Times and limits

Signature

35
Q

What is a nursing order

A

Instructions on how and when nursing interventions will be implemented

Usually on nursing care plan

Possibly can be delegated

RN may delegate but remains accountable for the patient

36
Q

Safe Nursing orders

A

Provide goal directed, client centered care

Use evidence based care

Provide safe quality care

37
Q

Implementation

A

Promote client participation

May delegate but remain accountable(most include supervision)

Can not delegate intervention that requires independent specialized nursing skill

38
Q

Five rights of delegation

A

Right task

Right curcumstance

Right person

Right direction

Right supervision

39
Q

Final step of implementation

A

Documentation.

Record nurses activities and client response.

40
Q

Evaluation

A

Evaluate clients progress to goals

Effectiveness of nursing care plan

Quality of care in health care setting

41
Q

Types of evaluation

A

Structure

Process

Outcomes

42
Q

Structure

A

Focuses on setting where care is provided.

Explores how the organizations policies and procedures impact quality of care.

43
Q

Process

A

Focuses on the way care is provided.

The activities by RN and other members of teams.

Was care relevant, appropriate, etc.

44
Q

Outcomes

A

Focuses on measurable change in clients health as result of care

45
Q

Frequency and time of evaluation

A

Ongoing

Intermittent

Terminal

46
Q

Ongoing

A

Will continuously evaluate while implementing, after interventions, and every patient contact

47
Q

Internittent

A

Done at specific times

48
Q

Terminal

A

Describes patient health and progress towards goal when they are discharged.

49
Q

How to evaluate client progress

A

Review outcomes

Collect reassessment data

Judge goal achievement

Record evaluative statement

Evaluate collaborative problems

50
Q

Evaluating and revising care plan

A

Goals met-if all goals met discontinue care plan

Goals partially met-can revise care plan or give more time to achieve goal

Goals not met- examine entire care plan and see if revision is necessary

Revise care plan-must review each step of nursing process to decide how to revise care plan

51
Q

Checklist for evaluating care plan

A

Review assessment- changes may have occurred in data or client condition

Review diagnosis- diagnosis may require update

Review planning outcomes-outcome might need to be revised

Review planning interventions-might need to modify nursing orders

Review implementation-can be failure to implement or issues with how implementation occurred.

52
Q

Types of assessments

A

Initial and ongoing-are as their definition

Comprehensive -hollistic

Focused -targets specific problem

Special needs assessment

53
Q

Special needs assessment

A

Type of focused assessment that focuses on one area

Nutritional assessment

Pain asessment

Cultural assessment

Spiritual health assessment

Psychosocial assessment

Etc.

54
Q

Nursing health history

A

Is done during assessment.

Usually includes:

chief complaint
History of present illness
Past health history

55
Q

Different problem types (diagnostic reasoning)

A

Medical diagnosis

Collaborative problem

Actual nursing diagnosis

Risk nursing diagnosis

Possible nursing diagnosis

Syndrome nursing diagnosis

Patient stregths

Wellness nursing diagnosis

Nurs 101 Lecture (13 decks)

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