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AH-Lewis Ch. 1
Review Care Plan!
| Question | Answer |
|---|---|
| Nurses offer skilled care to those? | recuperating from illness or injury, advocate for pt's rights, teach pt's, support pt's and help them navigate the increasingly complex health care system |
| What is the unique focus of nursing? | the response of an individual or group to an actual or potential health problem or life process |
| What is nursing? | putting the pt in the best condition for nature to act |
| What is the unique function of the nurse? | to assist the individual, sick or well |
| What is an advanced practice nurse? | a nurse with a master's degree |
| What does a clinical nurse leader do? | oversees the care coordination of a distinct group of pt and activiely provides dirend pt care in complex situations |
| What did the team leader do? | planned and organized the care to be given to a goup of pts by other professional nusrses or non profressional health care workers such as licensed practical nurses and nursing assistants |
| What does managed care invole? | case managment |
| What does a nurse case manager do? | coordinates the clinical care of the pt across care settings, from admission through discharge from the hospital, through other agencies as needed and back home |
| Ethical delimmas can be created by? | the use of the new scientific knowledge and the inequality of access to technology advanced health care. |
| Access to the internet allows pts to? | obtain info about their health prob and health care that may or may not be accurate and reliable |
| In such a complex enviroment nurses must be able to? | think critically, problem sove, and make independent decisions that lead to the best outcome for pts. |
| What is critical thinking in nursing? | is an essential component of professional accoutability and quality nursing care |
| What do critical thinkers in the nursing practice use? | congnitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting and transformming info. |
| What is Healthy People? | program that involves government, private, public, and nonprofit orgaization in preventing disease and promoting health |
| What are the 2 goals of healthy people? | increase quality and length of healthy life, eliminate health disparities |
| What have leading health indicators been developed for? | to measure and record progress toward the attainment of these goals |
| Educational programs now put more emphasis on? | health promotion, maintenance and cost effective care that responds to the needs of culturally diverse groups and underserved populations |
| What is evidence based practice? | is the conscientious use of the best evidence in combination with clinician expertise and pt preferences and values in clinical decision making |
| Regularoty and accrediting agencies now require practice be based on? | evidence |
| With who did EBP begin? | archie cochrane |
| EBP encompasses? | research utilization and the conduct of research |
| How many steps are there is the EBP process? | five |
| What is step 1 of the EBP process? | asking a clinical question, most important and most challenging |
| A clinical question that is searchable and answerable creates? | the context for integrating reseach findings, clinical judgement, and pt preferences |
| What is step 2 in the EBP process? | efficient search for and collection of evidence based on the question |
| Where does the search begin? | with the strongest external evidence to answer the questions |
| What are time saving resources in the EBP process? | preappraised evidence like systematice reviews |
| What are considered the strongest level of evidence to answer questions? | systematic reviews of randomized controlled trials |
| Care based on expert opinion requires? | diligent, ongoing, rigorous outcome evaluation to generate stronger evidence. |
| What is step 3 in the EBP process? | is criticallly appraising and synthesizing studies found in the search |
| A successful critical appraisal process focuses on what 3 questions? | are the results of the study valid? what are the results? and are the finding clinically relevant to my pts? |
| What is the purpose of a critical appraisal? | to determine the value of the research to practice and not only to examine the flaws of a study |
| What is step 4 of the EBP process? | it is different depending on the strength and breadth of the evidence to answer the question |
| Without sufficient evidence what would the fourth step be used for? | would be to generate data to answer the question |
| How can data be obtained? | through outcome management initiatives or through the conduct of rigous research |
| What is step 5 of the EBP research? | is evaluation of identified outcomes in the clinical setting |
| Outcomes must reflect? | all aspects of the implementation and capture the interdisciplinary contributions elicited the the EBP process |
| How does one implement EBP? | nurses must continuously seet scientific evidence that supposts the care that they provide=] |
| The incorporation of evidence should take into account? | the pt's unique circumstances and preferences |
| EBP closes the gap between? | research and practice |
| Care is based on what? | tradition, opinion, and trial and error |
| Evidence can support? | current practice and increase confidence that nursing care will continue to produce the desired outcome |
| What are stanardized nursing terminologies? | they are used to clearly define and evaluate nursing care |
| A readily understood common language can? | improve communication amoung nurses |
| How does standardized language help nursing practice? | It helps nurses to easily collect and analyze nursing data to identify the effectiveness of nursing interventions |
| Standardized terminologies offer? | ways to organize and describe nursing phenomena |
| The nusring management minimum data sat is for? | nursing management minimum data |
| What are the 3 classification systems recognized by the ANA? | NANDA, nursing intervention classification , and the nursing outcomes classification |
| What is an electronic health record? | a computerized record of all of the health info relate to an individual that can be electronically accessed by a variety of health care providers |
| Who developed the EHR? | the VA |
| EHR makes records? | fully electronic, portable, and accessible |
| All electronic records have to have? | passwords |
| What is nursing informatics? | a nursing specialty integrating nursing science, computer science, and informatiion science in identifying, collecting, processing, and managing data and information to support nursing practice, admin., education, research and the expansion of knowledge |
| What does an informatics nurse do? | designing, developing, marketing, and test to implementation, training, use, maintenance, avaluation, and enhancement of computer systems |
| What is the nursing process? | an assertive, problem solving approach to the identification and treatment of pt problems |
| What does the nursing process require? | thinking, reasoning, doing, feelings, values, skills and abilities of a nurse |
| What are the 5 phases of the nursing process? | assessment, diagnosis, planning, implementation, and evaluation |
| What is assessment? | collection of pt information on which to base the plan of care |
| What is nursing diagnosis? | is the act of identigying and labeling human responses to actual or potential health probelms/life processes |
| What happens during planning? | the nursing diagnosis directs the development of pt outcomes or goals and identification of nursing interventions to accompish the outcomes |
| What is implementation? | the activation of the plan with the use of nursing interventions |
| What step of the nursing process is continous? | evaluation |
| what is evaluation? | determines if the pt outcomes have been met as a result of nursing intervention |
| What happens if the outcomes were not met? | review of the steps of the process is necessary |
| Critical thinking the most important for? | for the diagnosis phase |
| What professions use problem solving processes? | nursing profession and the medical profession |
| Nursing practice has? | independent, dependent, and collaborative functions |
| How does a nursing function when she carries out medical orders? | dependently |
| The nurses role is in most cases? | interdependence and co participation |
| What is the collaborative nursing role? | where the nurse is primarily responsible for monitoring for possible or actual complication and for treating the pt to prevent or manage the complication |
| Where is the collaborative role frequently deomonstrated? | in the intesive care unit |
| What is the foundation for appropriate diagnosis, planning and intervention? | accurate collection of data |
| All information gathered should be varified by the? | patient |
| How does the diagnosis phase begin? | by clustering information |
| how does the diagnosis phase end? | with an evaluative judgement about a pt's health status |
| What does analysis involve? | recognizing cues, sorting through and organizing info. and determining pt strengths and unmet needs |
| Nursing diagnosis describe what? | health states that nurses can legally diagnose and treat |
| What is NANDA? | is a nursing organization that has been developing a standardized nursing terminology for identifying, defining, and classifying patients actual responses to health problems |
| How may nursing diagnostic statement be written? | one part, two part or three part statements |
| What are one part statements used for? | for wellness nursing diagnosis, when and individual is in transition from a specific level of wellness to a higher level of wellness |
| What are 2 part statements used for? | identify only the problem and etiology is acceptalbe if the signs and symptoms data are easily accessible to other nurses caring for the pt |
| What are also 2 part statments? | risk nursing diagnosis because signs and symptoms are not present |
| What are 3 part statements used for? | during the learning process |
| What does a 3 part statement do? | identifies the critical thinking process that occurs in making the judgment about the pt's health status. |
| What format is used in a 3 part statement? | PIE charting |
| What is PES charting? | Problem, Etiology, and signs and systoms |
| What is etiology? | a brief description of the probable cause of the problem, and relating factors |
| What is taxonomy? | the classification of things into an ordered system based on natural relationships |
| What does etiology provide? | direction for managing the problem |
| What is taxonomy? | classification of things into an ordered system based on natural relationships |
| Who are the basic users of taxonomy? | scientists, informaticists, and managers |
| Etiology= | cause |
| The etiology may be identified as? | second to the medical problem |
| The etiology is written after? | the diagnostic label |
| They are seperated by the words? | related to |
| What happens if the etiology is not included in the diagnosis? | the nurse is not able to plan the correct intervention to treat the specific cause of the problem |
| When the etioloty is unknown you write? | related to etiology unknown |
| There is often no single cause of the? | problem |
| signs and symptoms are also called? | difining charecteristics |
| what kind of characteristics must be present in the assssment data to make an accurate nursing diagnosis? | critical |
| What kind of characteristics are those signs or symptoms that are usually present to have an actual nursing diagnosis? | major |
| Minor characteristics are defined as? | possible nursing diagnosis |
| How are signs and symptoms wrote into the diagnostic statement? | as evidenced by |
| What are collarborative problems? | potential or actual complications of disease or treatment that nurses treat with other health care providers |
| During the diagnosis phase the nurse also identifies? | physiologic complications |
| In the interdependent role nurses use? | physicial prescribed and nursing prescribed interventions to prevent, detect, and manage problems |
| Collaborative problems are written as? | potential complications |
| Diagnosis of the highest priorities require? | immediate intervention |
| What makes a problem high prioritie? | A-airway, B-breathing, C-circulation |
| Physical needs should be met before? | psychosocial |
| What are pt outcomes? | describe to what degree the pt's responseidentified in the nursing diagnosis should be prevented or changed as a result of nursing care |
| What is nursing sensitive pt outcome? | an individual , family, or community state, behavior, or perception that is measured along a continuum in response to a nurse intervention |
| Outcomes should be set with? | the pt |
| What 2 methods are for pt outcomes? | writing specific outcomes or choosing outcomes from the nursing outcomes classification |
| How can a nurse write a pt outcome? | by describing desired, realistic, measurable pt behaviors to be accomplished by a specific date |
| What is the purpose of the NOC? | to evaluate the effects of nursing interventions, it is a list of concepts, definitions, and measures that describe pt outcomes influenced by nursing interventions |
| What do indicators describe? | the specific status of the pt in relation to the outcome |
| What is the 5 point measurement scale to rate the outcomes of pt's? | 1-severely compromised, 2- substantially compromised, 3-moderately compromised, 4-mildly compromised, 5-not compromised |
| What is the most desired measurement of pt outcome? | 5th |
| What can the nurse do when using the measurment scale? | can rate each indicator for a particular pt at any given period of time |
| NOC outcomes are not? | prescriptive |
| What is a nursing intervention? | any treatment, based on clinical judgement and knowlege, that a nurse performs to enhance pt outcomes |
| Nursing intervetions include what kind of care? | direct and indirect |
| What should a nurse consider when choosing an intervention? | desired pt outcome, etiology, clinical practice, scientific principles, feasibility of success, acceptability to the pt, and capability of the nurse |
| What does the NIC (nursing intervention classifications) include? | interventions that nurses carry out, or direct others to carry out, on behalf of pts |
| NIC identifies both? | physiologic and psychosociol interventions |
| NIC does not? | prescribe interventions for specific situations |
| The nurse is responsible for? | making the important decisions of when to use an interventions and for whom |
| Carrying out the specific, individualized plan constitutes what phase of the nursing process? | implementation |
| What is delegation? | is the transfer of responsibilites for theperformance of an activity from one person to another while retaining accoutability for the outcome |
| What is an unlicensed assistive personnel? | an unlicensed individual who is trained to function in a nassertive role to the professional nurse |
| What are professional nurses responsible for? | defining and supervising the education, training, and use of UAP in providing direct pt care |
| throughout the implementation phase the nurse must? | eveluate the effectiveness of the method chosen to implement the plan |
| At the end of the evaluation a nurse should? | determine whether the plan should be maintained, modified, discontinued or referred to another health care professional |
| What does documentation provide? | evidence that nursing practice standards related to the nursing process have been maintained during care of the pt |
| What are examples of documentation methods? | SOAP (IER) PIE DAR and CBE |
| Where are care plans used? | nursing education |
| When standardized care plans are used they should? | be personalized and specific to the unique needs and problems of each pt |
| What is a concept map? | another way of recording a nursing care plan |
| concept maps are used usually in? | nursing education to learn care plans |
| What is a clinical pathway? | is a plan that directs the entire health care team in the daily care goals for select health care problems |
| What does the clinical pathway describe? | the pt care required at specific times in the treatment |
| past and current definitions of nursing are common hw? | health, illness and caring |
| What is interpretation? | actively interpreting problems as well as objective and subjective data from common info. sources, related to the care of the pt |
| What is analysis? | examining ideas in problems, objective and subjective data and possible courses of action related to the care of a pt |
| What is inference? | querying claims, assessing arguments and reaching conclusions which are appropriate to the care of a pt |
| What is explanation? | clearly explaining and defending the reasoning in which an individual arrives at specific decisions in the context of the health care of the pt |
| What is evaluation? | evaluating info to ascertain its probable trustworthiness as well as ins relevance to particualar pt care situations |
| What is self regulation? | constantly monitoring ones own thinking using universal criteria |
| What is critical listening? | a mode of monitoring how we are listening so as to maximize our accurate understanding of what another perosn is saying |
| What is critical thinking? | disciplined, self directed thinking which implies the perfection of thinking appropriate to a particualar mode or domain of thinking |
| What is critical writing? | to express oneself in languages required that one arrange ideas in some relationships to each other |
| What is critical reading? | active, intellectually engaged process in which the reader participated in an inner dialogue with the writer-entering into a point of view of the writer |
| What is critical speaking? | active process of expressing verbally a point of view, ideas and thoughts such that others attain an in depth understanding of the speaker's personal perspective on an issue |
Created by:
alicia.rennaker
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