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Fundamentals Ch16-20

Test 2

QuestionAnswer
The Nursing Process is the fundamental... blueprint for how to care for patients.
the Nursing Process is also a standard of practice, which, when followed correctly, protects nurses... against legal problems related to nursing care.
With the Nursing Process, you perform assessment to gather information needed to... make an accurate judgement about a patient's current condition.
The data collected during assessment is obtained from either:... (5) the patient, the family, a member of the health care team, medical records, or medical literature.
Data is collected through the patient via... (3) patient-centered interviews, nursing health history, physical examination, results of lab/diagnostic tests.
A successful patient-centered interview requires... preparation.
A patient-centered interview involves... (4) setting the stage & agenda, collecting the assessment/nursing health history, terminating the interview.
When *setting the stage*, before you can collect personal health data, a patient has to sign... an authorization. due to HIPPAA regulations.
When *setting an agenda* during a patient-centered interview, ask the patient for... a list of chief concerns or problems.
When collecting an assessment or nursing health history during a patient-centered interview, start with... open-ended questions.
When *terminating the interview* during a patient-centered interview, include both... a summary, and accuracy check of information collected.
Patients are forced do describe situations with more than one or two words when you use... open-ended questions.
Back channeling involves using... active listening prompts, such as "go on" and "uh-huh."
Back channeling encourages a patient to... give more information.
When *probing* a patient during an interview, ask as many questions as you can until the patient... has nothing else to say.
Clarify previous information by asking... close-ended questions.
You gather a *nursing health history* during either... your initial or an early contact with the patient.
The information in a patient's health history provides data on both... the patient's health care experiences and current health habits.
You can collect data on a patient's self-reported data on all body systems with the... *Review of Systems* (*ROS*)
A physical examination is used to collect data by investigating the body to... determine its state of health.
Data is collected from diagnostic and laboratory tests which provide further explanations of alterations or problems identified during either... the nursing health history, or physical examination.
One critical thinking aspect of assessment is continuous *interpretation* of... data.
As you *interpret data* and form a database, you begin to see *data clusters* which are... groups of signs and symptoms that you group together in a logical way.
Data clusters clearly identify a patient's... health problems.
To avoid making incorrect inferences, before you complete *data interpretation* always... *validate the data*.
*Validation* of assessment data is... the comparison of data with another source to determine data accuracy.
*Data validation* opens the door for... gathering more assessment data.
Data validation opens the door for gathering more assessment data because it involves... clarifying vague or unclear data.
identification of a disease based on eval of physical s/s, the pts medical hx & results of diagn tests & procedures medical is AKA diagnosis.
A *Nursing Diagnosis*, the second step of the *Nursing Process*, is a formal statement of... an actual or potential health problem that a nurse can legally and independently treat.
Examples of nursing diagnoses are... acute pain, and nausea.
Diagnoses that require treatment by multiple disciplines are known as... *collaborative problems*.
A nursing diagnosis is essential because accurate diagnosis of patient problems ensures that you... select more effective and efficient nursing interventions.
The diagnostic process flows from the assessment process and includes... decision making steps.
Nursing diagnoses are outlined by... NANDA international.
The steps included within the *diagnostic* process include:... (3) data clustering, identifying patient health problems, and formulating the diagnosis.
A *data cluster* is a set of... signs or symptoms, gathered during assessment, that you group together in a logical way.
*Data clusters* are patterns of data that contain... *defining characteristics*
*Defining characteristics* are clinical criteria that are both... observable and verifiable.
*Defining characteristics* support... identification of a nursing diagnosis.
Often a patient has defining characteristics that apply to... more than one diagnosis.
When interpreting data to form a diagnosis, remember that the absence of certain defining characteristics suggests that you... reject a diagnosis under consideration.
Always examine the defining characteristics in your database carefully to either... support or eliminate a nursing diagnosis.
To individualize a nursing diagnosis further, you identify the associated... *related factor*.
A *related factor*, for example an etiology, explains... factors that lead to the defining characteristics.
The three types of nursing diagnoses, as defined by NANDA-I (international), include:... *actual nursing diagnoses*, *risk diagnoses*, and *health promotion diagnoses*.
An *actual nursing diagnosis* is a judgment that is clinically validated by the presence of major... defining characteristics.
A *risk diagnosis* describes human responses to health conditions/life processes that may develop in... (3) a vulnerable individual, family, or community.
A *health promotion nursing diagnosis* enhances things such as... nutrition and exercise.
Planning involves... (3) setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions.
Priority setting is the ordering of either... nursing diagnoses or patient problems.
Priority setting involves using determinations of urgency and/or importance to establish a... prioritized order for nursing actions.
Once you identify nursing diagnoses for a patient, you should set both... *Goals* and *Expected outcomes*.
A *Goal* is a broad statement that describes a desired... change in a patient's condition or behavior.
An *expected outcome* is a measurable criterion to evaluate.... *goal* achievement.
*Outcomes* and *goals* reflect patient behaviors and responses expected as a result of... nursing interventions.
Write a *goal* or *expected outcome* to reflect a... patient's specific behavior
Do not write a *goal* or *expected outcome* to reflect... your goals or interventions.
Each goal and outcome should address only one behavior or response to pinpoint... where the plan of care needs modification.
Singular goals and outcomes should always be... (5) observable, measurable, time-limited, contain mutual factors (i.e., for the patient and the nurse), and be realistic.
Part of the planning process involves meeting the patient's goals and outcomes by selecting... appropriate nursing interventions.
The actual implementation of nursing interventions occurs... during the implementation phase of the nursing process.
When selecting the correct nursing intervention, the six important factors to consider are:... characteristics of NRSG diagnosis, expect outcomes, research base, feasibility, acceptability to the patient, capability of the nurse.
As you select the NRSG interventions, review your Pt’s needs, priorities, & previous experiences to select the interventions that... have the best potential for achieving the expected outcomes.
In regards to *characteristics of the nursing diagnosis*, intervention should first alter... the etiological factor associated with the diagnosis.
regards to characteristics of the NRSG diagnosis, if etiological factor can’t be resolved, attempt to direct the intervent to treating... . the signs and symptoms
In regards to *feasibility*, intervention includes consideration of both... time and cost.
In regards to *capability of the nurse*, interventions requires the nurse to have both efficient.... psychosocial and psychomotor skills.
There are multiple expected outcomes within a given.... goal of care.
Implementation, the fourth step in the nursing process, formally occurs after... the nurse develops a plan of care.
A *nursing intervention* is any treatment based on clinical judgement on knowledge that a nurse performs to... enhance patient outcomes.
The two forms of nursing interventions are... *Direct care* interventions & *Indirect care* interventions.
Standards for the implementation step of the Nursing Process are defined professionally by... the American Nurses Association (ANA)
A *standing order* directs... the conduct of patient care in a specific clinical setting.
If in the patient's best interest, *standing orders* give the nurse legal protection to... intervene appropriately.
Activities usually performed throughout a normal day, including ambulation, eating, dressing, bathing, and grooming, AKA *Activities of Daily Living* (*ADLs*)
Evaluation, final step of the nursing process, is crucial to determine if, after application of the nursing process, the patient's... condition or well-being improves.
You conduct *evaluative* measures NOT to determine if nursing interventions were completed, but to determine... if your patient met *expected outcomes*.
The *expected outcomes* established during *planning* are the standards against which the nurse judges both whether.. *goals* have been met and if care is successful.
Once you deliver an intervention, you gather from the patient, family, and other health care team members both.. subjective (symptoms) and objective (signs) data.
Positive evaluations occur when the patient... meets expected outcomes.
A patient meeting expected outcomes in a positive evaluation indicates that... the nursing intervention(s) were effective.
nurse critically evaluates/revises therapies until the Pt & the nurse successfully & appropriately resolve the problems defined by... the nursing diagnosis.
The objective criteria needed to judge the patient's response to care are... the goals and expected outcomes.
A *goal* is the expected... BEHAVIOR or RESPONSE
An *expected outcome* is the end result that is... MEASURABLE, DESIRABLE, and OBSERVABLE
Created by: slyarrington