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The.Nursing.Process*

vocabulary words and notes

QuestionAnswer
Nursing Process systematic method in which the nurse & client work together to plan & carry out effective nursing care
Trial & error problem solving experimental approach that tests ideas to decide which methods work & which methods don't work
scientific problem solving precise method of investigating problems & arriving at solutions
critical thinking process of objective reasoning; analyzing facts to reach a valid conclusion
nursing care plan-ncp written list of the client's problems, goals & nursing orders for client care; guidelines used by healthcare facilities to plan the care for clients
what are the steps in the nursing process? nursing assessment, nursing diagnosis, planning, implementation, evaluation
prioritization, prioritizing following specific steps to determine the client's most important needs
client oriented focused on meeting individualized needs
goal oriented establishment of objectives or specific desired outcomes early in the nursing process
what is the method used to identify & treat client care problems? nursing process
nursing assessment systematic & continuous collection of data; analysis of information about the client
potential needs needs which may occur; identified as at risk for...
objective data facts that are observable & measurable
subjective data information that only the client feels & can describe; what client tells you
observation assessment tool that relies on use of 5 senses to discover information abot the client
what 3 methods are used to collect data? observaton, interview, physical assessment(examination)
health interview or nursing history way of soliciting information from the client
admission interview if the interview is conducted when a client is admitted to a healthcare facility
medical history if the interview is obtained by the physician
the purpose of a health history(interview) is... to enable the nursing staff to plan effective & personalized care that will meet clients individual needs
nursing progress notes, also called nurses notes documentation by nurses of care given & observations made
data analysis analyzing each piece of information to determine its relevance to a client's health problems & its relationship to other pieces of information
assessment systematic collection of information
signs objective data-information that is observable & measurable
symptoms subjective data-information that the client can only identify
what are the types of assessments? database assessment, focus assessment, functional assessment
database assessment initial information about the client's physical, emotional, social, & spiritual health
focus assessment information that provides more details about specific problems
functional assessment determining a person's ability to perform self care task
when does the nursing process begin to be utilized? as soon as you enter a nurse-client relationship
nursing diagnosis health problem that can be prevented, reduced, or resolved through independent nursing actions
medical diagnosis statement formulated by a primary healthcare provider that identifies the disease a person is believed to have
prognosis projected client outcome
what are the parts to a nursing diagnostic statement? problem-NANDA etiology-cause signs/symptoms
which type nursing diagnosis don't include the third part of the diagnostic statement? risk diagnosis & possible diagnosis
collaborative problems problem in which nurses work with physicians or other healthcare providers
by what medical abbreviation are collaborative problems identified on a client's paln of care PC-potential complication
diagnosis identification of health related problems; recognition of a disease by its signs & symptoms made by a physician
what are the 5 categories of nursing diagnosis? actual, risk, possible, syndrome, wellness
actual diagnosis problem that currently exist
risk diagnosis problem a client is at risk for developing
possible diagnosis problem that may be present but requires more data collection to rule out or confirm its existance
syndrome diagnosis cluster of problems that is present due to an event or situation
wellness diagnosis situation in which a healthy person obtains nursing assistance to maintain his/her health
planning process of prioritizing nursing diagnosis & collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions & documenting the plan for care
expected outcome measureable behavior that indicates whether a person has achieved the expected benefit of nursing care
goal expected or desired outcome
short term goal(objective) outcomes that can be met in hours, few days to a week
long term goals(objectives) outcomes that can take weeks or months to accomplish
nursing orders directions for a client's nursing care
standards for care policies that ensre quality client care
nursing interventions/nursing orders/nursing actions activities that will most likely produce the desired outcomes
kardex quick reference for current information about the client & the clients care
what are the characteristics of an expected outcome or goal? client centered, specific, reasonable, measurable
what is a formal guideline for directing the nursing staff to provide client care? nursing care plan
what is maslows hiearchy of needs in order? 1. physiologic 2. safety 3. love 4. esteem 5. self actualization
implementation to carry out a plan of care
dependent nursing actions actions that nurses must follow explicitly according to physicians orders
interdependent nursing actions actions that occur in cooperations with physicians & other team members
independent nursing actions nursing actions that don't require a physicians order
accountability responsibility for all actions that one performs
intellectual skills knowing & understanding essential information
interpersonal skills believing,behaving, & relating
technical skills skills used to perform interventions
evaluation process of determining whether a goal has been reached; measure the effectiveness
discharge planning process in which a client is prepared for continued care after discharge from a healthcare facility
concept mapping organizing information in a graphic or pictorial form
type of assessment that is repeated each shift or more often, takes about 15 minutes, is a collection of physical assessments, consists of unstructured questions, & rules out & confirms problems focus assessment
type of assessment that is obtained on admission, performed once, suggest possible problems, and is time consuming database assessment
type of assessment that has to be completed within the first 14 days of admission, is repeated at least every 12 months if no significant change, & identifies physical, psychological or social factors that affect self care functional assessment
following is examples of what type data: weight, temperature, skin color, blood cell count, vomiting, bleeding objective data
following are examples of what type data: pain, nausea, depression, fatigue, anxiety, loneliness subjective data
the following nursing diagnosis identifies which Maslows need: imbalanced nutrition; less than body requirements physiologic
the following nursing diagnosis identifies which Maslows need: Risk for injury safety & security
the following nursing diagnosis identifies which Maslows need: ineffective breathing pattern physiologic
medical records written collection of information about a person's health problems, care provided & progress of client
recording process of uniting information
documenting or charting process of entering information
chart binder or folder that enables the orderly, collection, storage, & safekeeping of a clients medical record
quality assurance, continuous quality improvement, total quality improvement process of promoting care that reflects established agency standards
auditors inspectors who examine client records
what are the types of client records? source oriented records & problem oriented records
problem oriented medical record records organized according to client's health problems in which heatlhcare team works collaboratively to identify priority problems
source oriented medical record records organized according to the source of information
what type of record contains separate forms for physicians, nurses, dietitians, physical therapist, etc to make entries about specific client care? source oriented medical record
what are the components of a problem oriented medical record? data base, problem list, plan of care, progress notes
health record manual or electronic account of a client's relationship with a healthcare facility
computerized charting documenting client information electronically
electronic medical record rapid form of documentation in healthcare facilities using various, individualized, computerized formats
manual health record a collection of various forms & documents
medication administration record list of all medicatios that the physician has ordered for a client; agency form used to document drug administration
what are the methods of charting? narrative, SOAP, focus, PIE, charting by exception
narrative charting chronological order; type of nurses' notes in which nurse documents what is occurring throughout the day
which method of charting, resembles a log or journal? narrative charting
type of charting that is more likely to be found in a problme oriented medical record? SOAP charting
charting method that demonstrates interdisciplinary cooperation with all healthcare personnel, making entries in same location on chart? SOAP charting
focus charting charting that focuses on a specific problem
PIE charting charting which involves numbering problems & documenting assessments on a separate form
charting by exception documentation in which only abnormal assessment findings or care that deviates from the standard is charted
progress notes form nurses fill out at regular intervals to summarize a client's condition or response to treatment
case management providing high quality care while effectively using healthcare resources & controlling cost
minimum disclosure portions of isolated pieces of information necessary for an immediate purpose
beneficial disclosure an exemption whereby an agency can release private health information without a client's prior authorization
how should an error be corrected in documentation? cross out incorrect statement with single line enclose it in parentheses write error & initial it
what are some guidelines to remember when documenting? document what you see, observe be specific when documenting use direct quotations for subjective data be prompt be clear, consistent
should assessments be documented subjectively or objectively ? objectively
how should the chart be signed? first initial, full last name, title or full first, last name, title
what should you do if you have a vacant line when charting? draw line through the vacant line
traditional time time based on 2-12 hour revolutions on a clock
military time time based on a 24 hour clock
checklist form of documentation in which nurse indicates with a check mark or initials that routine care has been performed
flow sheet form of documentation that contains sections for recording frequently repeated assessment data
graphic flow sheets graph, form, or picture that records large amounts of information collected at intervals over a specified period of time
change of shift reporting means of exchanging information between ongoing & incoming staff on each shift
walking rounds caregivers that move from client to client discussing pertinent information
rounds visits to clients on an individual basis or as a group
what are some things to tell nurse during change of shift report? name, age, room number, code status, diagnosis on admission, primary healthcare provider, lab test, scheduled test, surgeries, procedures, diagnostic studies, vital signs, iv site, fluid, rate, pain level, what relieves pain, activity level, diet, meds
what content may the fact sheet provide? clients name, date of birth, address, phone number, religion, insurer, admitting physician, admitting diagnosis, emergency contact & number
what type of form provides instructions about the client's choices for care if they become unable to make decisions later? advance directive
what type of form contains physicians review of client's current & past health problems, results of body system exam, medical diagnosis, or tenative plan for treatment? history & physical examination
what form identifies lab & diagnostic test, diet, activity, meds, IV fluids, & clinical procedures? physicians orders
what type form describes clients ongoing status & responses to current plan of care & potential modifications in plan? physicians or multidisciplinary progress notes
which form documents information concerning the client's health patterns & initial physical assessment findings? nursing admission database
what type form identifies client problems, goals, & directions for care based on an analysis of collected data? nursing or multidisciplinary plan of care
what does the graphic sheet form convey information about? trends in vital signs, weight, I & O,
what type form indicates focused physical assessment findings by individual nurses during each 24 hour period & routine care provided? daily nursing assessment & flow sheet
what information does the Nursing Notes form provide? narrative details of subjective & objective data, nursing actions, response of client, outcomes of communication with other healthcare personnel or client's family
what information is obtained on the Medication Administration record form? drug name, date, time, route, frequency, name of nurse administering medication
what form contains the results of tests in a sequential order? laboratory & diagnostic reports
what form identifies content that was taught, evidence of client's learning & need for repitition of reinforcement? teaching summary
admission entering a health care agency for nursing care & medical or surgical treatment
orientation helping a person to become familiar with a new environment
discharge termination of care from a health care agency
transfer moving a client from place to place; discharging a client from one unit or agency & immediately admitting them to another agency
referral process of sending someone to another person or agency for special services
stepdown units, progressive care units, transitional care units units for clients who were once in critical condition but have recovered sufficiently to require less intensive nursing care
transfer summary written review of the client's previous care
clinical resume summary of previous care
extended care facility healthcare agency that provides long term care
skilled nursing facility nursing home that provides 24 hour nursing care under direction of a RN
intermedicate care facility agency that provides health related care & services to people who require institutional care but not 24 hour nursing care because of mental of physical condition
basic care facility agency that provides extended custodial care
continuity of care uninterrupted client care despite the change in caregivers
home health care in home healthcare provided by an employee of a homehealth agency
double charting repititious entry of same information in the medical record
NCP nursing care plan
UAP unlicensed assistive personnel
ADL activities of daily living
CC client complaint
NANDA(I) north american nursing diagnosis association(international)
AEB as evidenced by
R/T related to
POMR problem oriented medical record
MIS management information systems/services
EMR electronic medical record
MAR medication administration record
RAP resident assessment protocol
MDS minimum data set
CBE charting by exception
SOAP subjective, objective, assessment, plan
SOAPIER subjective, objective, assessment, plan, implement, evaluation, response
PIE plan, intervention, evaluation
APIE assessment, plan, implementation/intervention, evaluation
DAPE data, assessment, plan, evaluation
DARE data, action, response, education
DARP data, assessment, response, plan
RIE recorded in error
Created by: 1115060100