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Chapter 6/7 stdguide
studyguide
| Question | Answer |
|---|---|
| nursing process | creative, logical, scientifically based problem solving process for providing client care |
| purpose of nursing process | to identify, diagnose, and treat actual or potential human responses to health and illness |
| caring for clients incorporates _____________ and critical thinking behaviors | nursing process |
| _____________ is responsive to changes in clients needs (flexible-changing as client's condition changes) | nursing process |
| _____________ helps nurse to manage each patient's care scientifically, holistically, and creatively | nursing process |
| 5 phases of nursing process | ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation |
| purpose of assessment | to establish a data base |
| components of assessment | interview & health history, physical examination |
| physical examination techniques | IAPP: inspection, auscultation, palpation percussion |
| auscultation | listening to body sounds w/stethoscope |
| palpation | use of hands |
| percussion | tapping on body surface to determine density of underlying tissue |
| primary source of data for assessment | client/patient |
| secondary source of data for assessment | family members, friends, nurse's own observations |
| tertiary source | medical records, other medical staff |
| subjective data | what subject says; what patient tells you; no objective proof for data; examples: pain, nausea |
| objective data | what nurse can observe, measure (see, feel, smell, etc.); examples: vital signs, diagnostic studies, laboratory values |
| nursing diagnosis | process of identifying specific client responses to actual or potential health problems or life processes (identification of problems and/or strengths) |
| a _____________ identifies a disease condition | medical diagnosis |
| a _____________ identifies response of patient or patient's body to that disease process/problem/condition | nursing diagnosis |
| _____________ change as client's responses change | nursing diagnoses |
| _____________ distinguish nurse's role from physician's role | nursing diagnoses |
| _____________ are those client responses that are legally treatable within domain of nursing | nursing diagnoses |
| _____________ is delineated by state Nurse Practice Act | nursing domain |
| begin phase of _____________ by clustering and analyzing | nursing diagnosis |
| data cluster | a set of signs or symptoms that are grouped together in a logical order |
| data cluster | cues or groups of data indicating a client problem or health need |
| diagnostic labels | (the problem in the diagnostic statement) are NANDA approved |
| NANDA | provides nurses with common terminology |
| types of nursing diagnoses - actual | a need or a problem actually exists |
| types of nursing diagnoses - actual | describes a human response to health conditions or life processes that exist in individual, family, or community; example: impaired skin integrity |
| types of nursing diagnoses - risk (potential) | there is an increased chance that the problem will develop |
| types of nursing diagnoses - risk (potential) | describes human responses to health conditions or life processes that have a chance of developing in a vulnerable individual, family, or community; example: risk for infection |
| types of nursing diagnoses - wellness | there is readiness for improvement/enhancement |
| types of nursing diagnoses - wellness | describes human responses to levels of wellness in individual group, or community that have a readiness for enhancement or improvement; example: readiness for enhanced coping |
| types of nursing diagnoses - wellness | client wishes to achieve an optimal level of health |
| types of nursing diagnoses - possible | nurse does not have enough data to confirm diagnosis...only enough to suspect a problem or need; RNs response is to gather more data |
| formula for nursing diagnostic statement | problem (diagnostic label-NANDA approved) related to + etiology (cause) of the problem + as evidence by signs & symptoms of problem |
| ________________ must be within domain of nursing practice & condition that will respond to nursing interventions | etiology |
| etiologies exist in these categories | biological/psychological, treatment related, situational (environmental or personal), & maturational |
| ________________ has only 2 parts: problem related to r/t etiology | risk diagnosis |
| ________________ is risk factor | etiology |
| ________________ it explains cause of risk | etiology |
| example of complete nursing diagnostic statement | knowledge deficit, course: health promotion r/t failure to study assignment as evidenced by grade avg. 50% (obj. data) & student's statement (subj. data), "I don't understand class material, but then, I haven't read assignments or studied my notes." |
| planning: step #1 | establish client centered outcomes/goals. |
| expected outcomes/short term goals | steps toward goal achievement; these will be achieved over hours to weeks |
| long term goals | reflect ultimate/best outcome/resolution of the problem & is achieved over weeks to months |
| long term goal | will indicate that problem has been solved |
| properly constructed outcomes/goals will be | client behavior/client centered |
| properly constructed outcomes/goals will be | singular (include only one client behavior) |
| properly constructed outcomes/goals will be | observable |
| properly constructed outcomes/goals will be | measurable |
| properly constructed outcomes/goals will be | time limited: within specific time frame |
| properly constructed outcomes/goals will be | realistic |
| developed with client & serve as criteria for evaluation | outcomes/goals |
| excellent goals/outcomes | will be one client behavior that is realistic, observable, measurable & contains time frame; e.g., client will have soft, formed bowel movement by 0800, 10/4/09 |
| planning: step #2 | select interventions (nursing actions are chosen/decided upon) |
| interventions | those nursing actions that will assist client in reaching outcomes/goals (assist in resolving problem) |
| types of nursing interventions - nurse initiated | within scope of Nurse Practice Act |
| Nurse Practice Act | those actions nurse may take independently...no doctor's order needed |
| types of nursing interventions - physician initiated | based on physician's response to treat or manage medical diagnosis |
| types of nursing interventions - collaborative | therapies that require knowledge, skill & expertise of multiple health care professionals |
| interventions | must be appropriate, address problem identified in nursing diagnosis, & move client toward goal achievement |
| interventions | written as nursing orders (specific nursing actions to assist client's in reaching goals) |
| interventions | must be specific, concise, & individualized for client |
| nursing orders | direct nursing staff in client's care |
| nursing orders include instructions to | assess, administer, monitor, provide, perform, or teach |
| implementation | the carrying out of interventions |
| implementation | nursing actions: assessment, dressing changes, etc., doing! |
| evaluation | measurement of client's response to nursing interventions & client's progress toward achieving goals |
| evaluative statement | declare whether goal was met, not met, or partially met |
| evaluative statement | describe how it was met or partially met or why it was not met |
| if goals were not met, __________________...entire sequence of nursing process is repeated...beginning w/assessment | nursing process begins again |
| if goals were met, ________________ | nursing care plan is discontinued |
| nursing care plan | addresses one client problem/need |
| nursing care plan | one nursing diagnosis & is written guideline for individualized care |
| nursing care plan | developed for each nursing diagnosis |
| nursing care plan includes | nursing diagnostic statement |
| nursing care plan includes | short & long term expected outcomes/goals |
| nursing care plan includes | interventions (nursing orders) |
| interventions | actions that will lead to resolution of client problem |
| intervention | each one must have scientific rationale |
| scientific rationale | explains why/how intervention will assist client in reacting outcomes/goals & eventually resolve problem stated in nursing diagnosis |
| nursing care plan includes | evaluative statment |
Created by:
chaptravelman
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