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Stack #171444
Nursing Process- Potter and Perry 7th Edition
| Question | Answer |
|---|---|
| A professional nurse's approach to identify, diagnose, and treat human responses to health and illness. | Nursing Process |
| A systematic, validation, communication collection of data as it is related to the client. | Nursing Assessment |
| The purpose of an assessment is to establish this about the client's perceived needs, health problems, and responses to health problems. | Database |
| Sources of obtaining data for Nursing Assessment: | 1)Primary Source 2)Secondary Sources:(Family and significant other),Health Care team,Medical records. |
| 3 Phases of Assessment Interview: | 1)Orientation- introduces self, your position, and explains purpose of interview. 2)Working- gather information about client's health status. 3)Termination- gives client a clue that interview is coming to an end. |
| This prompts clients to describe a situation in more than one or two words. | Open Ended Questions |
| This limits the client's answers to one or two words such as "yes" and "no" or a number or frequency of a symptom. | Closed Ended Questions |
| This is client told data. | Subjective Data |
| This is nurse observed data. | Objective Data |
| The 5 Steps of Nursing Process: | 1)Assessment,2)Diagnosis,3)Planning,4)Implementing,5)Evaluation. |
| Published in 1967. | The first nursing diagnosis book. |
| Clinical judgment about client response to actual or potential problem based on data collected during assessment. This provides basis for selecting nursing interventions to achieve outcomes. May change frequently. | Nursing Diagnosis |
| An actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status. | Collaborative Problem |
| Clusters and patterns of data contain this, a critical criteria or assessment findings that support an actual nursing diagnosis. Contains subjective and objective data. | Defining Characteristics |
| 4 Physical Assessment Techniques: | 1)Observation- what you see. 2)Auscultation- listening with or without stethoscope.3)Palpation- feeling with fingers.4)Percussion |
| Objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion. | Clinical Criteria |
| Describes human responses to health conditions/ life processes that will possibly develop in a vulnerable individual, family or community. | Risk Nursing Diagnosis |
| A clinical judgment of a person's, family's, or community's motivation and desire to increase well- being and actualize human health potential as expressed in their readiness to enhance specific health behaviors. | Wellness Nursing Diagnosis |
| The name of the nursing diagnosis as approved by NANDA International. | Diagnostic Label |
| A condition or etiology identified from the client's assessment data. It is associated with the client's actual or potential response. | Related Factor |
| The "why" of nursing diagnosis. Environmental or contributing factors. | Etiology |
| 5 Components of Critical Thinking: | 1)Specific Knowledge,2)Experience,3)Competencies,4)Attitudes,5)Standards. |
| 3 Basic Levels of Critical Thinking: | 1)Basic-based on rules or principles.2)Complex-separate from authorities. 3)Commitment-makes choices without assistance of others. |
| 3 Purposes of Nursing Process: | 1)Identify client's health needs,2)establish nursing care plan,3)complete interventions. |
| 3 Steps of Nursing Diagnosis: | 1)Data interpretation and analysis,2)Reaching conclusion,3)Formulating the nursing diagnosis. |
| Interpretation and Analysis of Nursing Diagnosis: | 1)Recognize significant data-compare to standards,2)Validate the data-recheck data, troubleshoot equipment, compare subjective and objective data, clarify patient statements with family or other staff.3)Recognize patterns or clusters. |
| 4 Types of Nursing Diagnosis: | 1)Actual,2)Risk for,3)Health Promotion,4)Wellness,5)Potential Complication. |
| Formulate diagnosis statement by using PES format. What does PES stand for? | P= problem: describe patient's health state.E= etiology: factors causing or contributing.R/TS= signs/ symptoms: data collected signaling existence of a problem. AMB |
| Only use these letters of PES when there is a risk for or Potential Complication problem exists. | PE |
| Utilizes the Nursing Diagnoses to determine the nursing action systems needed to formulate an individualized plan of care for the client to meet their needs. | Orem's definition of Planning Phase |
| The Planning Phase is of Nursing Process is composed of: | goals/ outcomes,interventions/ nursing orders. |
| 5 reasons why there is a Planning Phase of Nursing Process: | 1)to individual care,2)to set priorities (most important of all),3)to facilitate communication among staff,4)to promote continuity of care,5)to evaluate patient response to care. |
| The ordering of nursing diagnosis or client problems using notions of urgency and/ or importance to establish a preferential order for nursing actions. | Priority setting |
| The 3 Phases of Comprehensive planning-setting priorities: | 1)Initial- first patient contact.2)Ongoing- continuous to meet current needs.3)Discharge-extension of care after discharge. |
| Priorities are ranked as: | 1)High risk 2)Medium risk 3)Low risk |
| This risk if left untreated can cause harm to client or others. | High Risk |
| These risks are non- emergent, non- life threatening but are still important. | Medium Risk |
| This risk is not necessarily related to current condition. But if left alone affects future well being. | Low Risk |
| This is specific and measurable, client centered, highest possible level, only 1 behavior/ response, worded with a sentence (subject- client, verb, criteria, time). | Goal |
| This is the desired results of actions taken to achieve a broader goal, measurable steps toward achieving the desired results, multiple coutcomes in a goal, complete sentence not necessary (verb, criteria, time) | Outcome |
| Knowledge deficit r/t use of crutches AMB " I have never used crutches before." This is an example of? | A Nursing Diagnosis |
| Patient will walk unassisted with crutches by discharge. This is an example of? | A Goal |
| Voices understanding of instructions given after education, demonstrates appropriate technique for crutch walking (unassisted) prior to discharge to home. This is an example of? | Outcomes |
| There are 2 types of Goals:1) This goal has a time frame of 1 week or less.2) This goal has a time frame of several days to months. | 1) Short term goal. 2) Long term goal. |
| This is most important when setting goals. | Considering what the client is willing to do or can do. |
| A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. | Client- centered goal |
| Interventions are derived from this statement of the nursing diagnosis. | Etiology |
| This should be individualized, client specific, consistent with the standards of care, realistic in terms of abilities, resources, time and capatible with client's values and beliefs. | Interventions |
| 3 Types of Interventions of Nursing Process: | 1) Independent- initiated by nurse without directions of other healthcare provider.2) Dependent- carrying out physician directed orders.3) Collaborative-actions performed jointly with other healthcare providers such as PT,OT. |
| This enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. | Nursing Care Plan |
| What 4 questions will help you in designing a care plan intervention? | 1)What is the intervention?2)When should each intervention be implemented?3)How should the intervention be performed for this specific client?4)Who should be involved in each aspect of intervention? |
| Nursing Interventions should be these 4 C's: | 1)Clear2)Concise3)Complete4)Correct |
| Well written nursing orders include: | 1)Clear and concise described action.2)Use accepted abbreviations only.3)Dated when written.4)Signed by initiating nurse. |
| 5 Comprehensive Orders: | 1)Assessments- type, frequency.2)Direct Care Measures-instructs direct care staff of completing intervention.3)Teaching-instructs patient to use or educates.4)Counseling 5)Advocacy-speaks for client. |
| Types of Care Plans | 1)Standardized plan-most frequently used.2)Protocol3)Kardex4)Student care plan5)Case managementCritical pathway |
| This step of nursing process formally begins after the nurse develops a plan of care. It is the treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/ client outcomes. | Nursing Interventions |
| A document that guides decisions and interventions for specific health care problems or conditions. | Clinical guidelines or Protocol |
| A preprinted document containing orders for the conduct of routine therpies, monitoring guidelines, and/ or diagnostic procedures for specific clients with identified clinical problems. | Standing order |
| This system developed by the University of Iowa helps to differentiate nursing practice from that of other health care professionals. | NIC System |
| The NIC system offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. | NIC Interventions |
| Activities performed in the course of a normal day. Examples include: ambulation, eating, bathing, dressing, brushing teeth and grooming. | ADL (Activities of Daily Living) |
| Activities that allow the client to be independent in society. Examples include: shopping, preparing meals, writing checks, taking medications. | IADL (Instrumental Activities of Daily Living) |
| This part of the nursing process determines if after application of the nursing process the client's condition or well- being improves. | Evaluation |
| The process of Evaluation involves these 3 things: | 1)Identifing criteria- goals and outcomes.2)Collect evaluative data.3)Interpreting and summarize. |
| After Evaluation, a nurse makes these decisions: | 1)Terminate plan of care- no longer needed.2)Modify the plan-goal not met plan to achieve.3)Continue plan of care- goal not met, plan effective, plan still needed. |
| Evaluation is the formal mechanism to ensure quality of care. Name 5 ways to ensure quality of care: | 1)Quality Improvement (CQI,TQM)2)Quality Assurance (QA)3)Outcomes Management4)Nursing Audit5)Self-Evaluation |
| The transfer of responsibility for the performance of an activity from one individual to another while still retaining accountability for the outcome. | Delegation |
| These can't be delegated. | 1)Assessment2)Planning3)Evaluation4)Nursing judgement |
| 5 Rights of Delegation: | 1)Right task.2)Under right circumstances.3)To right person.4)With right directions and communication.5)Under the right supervision and evaluation. |
| 2 Types of Communication | 1)Verbal2)Written |
Created by:
just_mary1971
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