week 6 Flashcards
What are the 5 steps to the nursing process? Explain each step
1) assessment: collect data
2) nursing diagnosis: analyze data, identify health problems and formulate diagnostic statements
3) planning: prioritize problems, formulate goals and identify nursing interventions
4) implementation: reassess the patient, supervise delegated care, document nursing activities
5) evaluation: collect data relation to outcome, draw conclusion about problem status
Regarding Assessment, What are the 4 types?
1) initial: triage. helped determine the nature of the problem
2) focused: the problem is exposed and treated
3) time lapsed: once treatment has been implemented, time-lapsed assessment must be conducted to ensure the the patient is recovering
4) emergency: identifying the root cause of concern for the patient and assessing the airway
What are the 2 types of data?
subjective and objective
what are ways to collect data?
interview
form completion
chart review
diagnostic and lab results
Where do nursing diagnosis come from?
NANDA
T/F nursing diagnosis is the same as medical diagnosis?
false
What are the 5 different types of nursing diagnosis?
1) actual/problem-focused: describes human responses to health conditions or life processes
Ex: impaired skin integrity related to…as evidenced by…
2) risk nursing diagnosis: describes human responses to health conditions or life processes that MAY develop
Ex: risk for impaired skin integrity as evidence by…
3) syndrome diagnosis: cluster of diagnosis’ best understood together
Ex: chronic pain syndrome
4) Health promotion/wellness nursing diagnosis: describe human responses to levels of wellness that have a readiness for enhancement
Ex: readiness for enhanced family coping
5) Possible nursing diagnosis: describe a suspected problem for which additional data needed to confirm or rule out.
Ex: possible social isolation
What are the 3 components of a nursing diagnosis?
1) the problem which has 2 components
- focus on the diagnosis: Ex:”gas exchange”
- qualifier: Ex: “impaired”
2) the etiology: describe possible reasons for the problem or condition
- written “as related to”
3) the defining characteristics: signs and symptoms
- written as “as evidenced by”
What steps are included in the actual, risk and wellness diagnosis in terms of the nursing diagnosis components?
- actual has all 3 components
- risk had 2 components, problem and “as evidenced by”
- wellness has 2 components, problem and “ as evidenced by”
What are the 3 types of planning?
1) initial: admission assessment
2) ongoing: as a nurse obtains new information and evaluate the client’s response to care, can individualize plan
3) discharge: process of anticipating and planning for needs after discharge. NOTE discharge planning starts at the moment the client is admitted into the unit
what are the classifications of priorities? and the acronym
1) high
2) intermediate
3) low
ABC - Airway, Breathing, Circulation
how long is a short-term, intermediate and long-term
1) short-term: hours to week
2) intermediate goal: weeks
3) days, weeks to months
What do care plans outline and include?
outlines the care provided (incl. holistic)
includes, nursing diagnosis, interventions and patient focused
What are the different types of interventions?
1) nurse-initiated: independent
2) physician-initated: dependent
3) collaborative: interdependent
what are 6 factors to consider when selecting interventions?
1) character of nursing
2) goals and expected outcomes
3) evidence base for interventions
4) feasibility of the intervention
5) acceptability to the client
6) nurse’s competency
