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Nursing Process Ques

UTHSCSA N3802 Nursing Process

What is Assessment? gathering and collecting patient information
What is Diagnosis? identifying the patient’s problem
What is Planning? setting goals and identifying appropriate nursing actions
What is Implementation? performing nursing actions identified in planning
What is Evaluation? determining if goals are achieved
When is the nursing process completed? it is a continuous process, Evaluation is Assessment again
What are some critical thinking skills? interpretation, analysis, evaluation, inference, explanation, self-regulation
What are some critical thinking attitudes? confidence, thinking independently, fairness, responsibility and authority, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility
What are the 2 phases of assessment? collection of data and clustering data, recognizing patterns, and data analysis
What is subjective data? information reported by the patient in their own words
What is objective data? data that is measured or observed by a health care professional
What is more important subjective or objective data? neither
What are 4 data sources? the patient, family, other providers, medical record
What is the best source of data? the patient if cognant and alert
What are 2 ways data can be clustered? Gordon’s 11 Functional Health Patterns or by body systems
What are Gordon’s 11 Functional Health Patterns? Health Perception/Health Management; Nutrition/Metabolic; Elimination; Activity/Exercise; Sleep/Rest; Cognitive/Perceptual; Role/Relationship; Sexuality/Reproductive; Coping/Stress Tolerance; Value/Belief
What are the 7 body systems? respiratory, cardiovascular, nervous, gastrointestinal, musculoskeletal, genitourinary, integument
On what basis are nursing action or interventions based? nursing diagnosis
What are defining characteristics of a diagnosis? the cluster of signs and symptoms associated with the diagnosis
What is the etiology of a diagnosis? related factors; factors that cause or contribute to the problem
What is an actual diagnosis? clinical judgment that can be validated by the presence of defining characteristics; it is actually happening now
What are the parts of the actual nursing diagnosis? label, etiology, signs and symptoms
How is an actual diagnosis written? label R/T etiology (secondary to…) AEB signs/Symptoms
What is a risk diagnosis? Clinical judgment that an individual is more vulnerable to develop the problem
What is the difference between nursing interventions for a risk diagnosis vs an actual diagnosis? nusing interventions are aimed at prevention for risk diagnoses
What are the parts of the risk diagnosis? label, etiology
How is a risk diagnosis written? Risk for label R/T etiology
What are 5 sources of diagnostic errors? errors in data collection, interpretation, data clustering, diagnostic statement, or premature closure before gather enough information
What are some rules to remember in writing diagnostic statements? Only NANDA labels, use “related to” not “caused by,” make sure label and etiology do not restate each other, etiology is not a medical Dx, “secondary to” can be a medical Dx, don’t make judgmental statements, don’t suggest others not doing job
What are the stages of Maslow’s Hierarchy? physiological needs: O2, fluids, food, temp, elim, shelter, sex, physical and psychological safety, love and belonging needs, self-esteem needs, self-actualization
How can priorities of different diagnoses be established? use Maslow’s Heirarchy
What are the guidelines for writing goals? ”the patient will…”, 1 goal per diagnosis, realistic, measurable, time limited, mutual, short or long term, can have multiple outcomes
What is included in a goal statement? who, what behavior, how measured, when
What are guidelines for writing nursing actions/interventions? ”the nurse will…”, based on etiology, based on rationale, generally focused on promoting, maintaining, or restoring health
What are 3 categories of nursing actions? independent (nurse initiated), dependent (physician initiated), collaborative (requires knowledge, skill, and expertise of multiple health care professionals)
What are 3 types of independent nursing actions? diagnostic, therapeutic, educational
What are 5 things it takes to be competent in the nursing process? Be a critical thinker; Experiential & theoretical knowledge; Interpersonal communication skills; Technical skills; Willingness & Ability to Care
Created by: dietrichl
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