Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
nursing chapter 4
chapter 4
| Question | Answer |
|---|---|
| nursing process | a decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them. |
| care plan | is a documented plan for giving patient care and includes the health-care provider’s orders, nursing diagnoses, and nursing orders. |
| critical thinking | is using skillful reasoning and logical thought to determine the merits of a belief or action. |
| validate | or ensure the correctness of, the information they obtain. It is sometimes tempting to simply “do what you are told” or to “just follow orders” rather than to think critically about your nursing practice. |
| nursing process. | In addition to learning to think critically, you must learn to make nursing decisions using a framework for decision making known as the nursing process. |
| ADPIE | Assessment, diagnosis, planning, implantation, evaluation |
| Assessment | gathering of information through signs and symptoms, patient history, and both subjective and objective findings. Just as a health-care provider gathers information by performing a physical examination and a patient history, |
| Assessment 2 | the nurse gathers information about the patient through asking questions (interviewing), performing a head-to-toe assessment, and reviewing laboratory and diagnostic tests. |
| Diagnosis | is the formulation of nursing diagnoses through an analysis of the assessment information that you have gathered. Nursing diagnoses are related to the needs or problems a patient is experiencing. |
| diagnosis 2 | These are completely different from medical diagnoses and are selected based on definitions and defining characteristics. |
| Planning | is the process of determining priorities and what nursing actions should be performed to help resolve or manage each patient problem. In addition, the nurse determines expected outcomes for the patient to meet for the nursing diagnosis to be resolved |
| planning 2 | , as well as a realistic time frame for that to occur. The nurse then decides on appropriate interventions to resolve each patient problem or nursing diagnosis. |
| Implementation | is the process of taking actions to resolve the patient’s problems (i.e., the nursing diagnoses). These actions are also called interventions. |
| implementation 2 | When the nurse performs these interventions, it is called implementation. The nurse implements the plan to help resolve the patient’s problems. |
| Evaluation | is performed when the nurse reflects on the interventions performed and decides whether the patient is now closer to achieving the goals |
| evaluation 2 | and outcomes set in the planning step. If not, the nurse then revises and changes the interventions and perhaps the goals to better fit the needs of the patient. |
| 3 components to assessment | Interviewing, which involves asking questions, listening, and using both verbal and nonverbal communication skills -Performing a focused body system assessment to determine deviations from normal in the patient’s physical condition |
| 3 components to assessment - continued | -Reviewing the results of laboratory and diagnostic tests to determine problems and needs caused by abnormal findings |
| Objective data | data are those things that you can observe through your senses of hearing, sight, smell, and touch. Examples of objective data include “pale, cool, moist skin” and “dark brown, formed bowel movement |
| subjective data | Information that is known only to the patient and family members |
| Use of Senses to Obtain Objective Data | vision, hearing, smell or touch |
| rapport, | creating a relationship of mutual trust and understanding. |
| primary data | When the patient provides information |
| secondary data. | When you obtain information from family members, friends, and the patient’s chart |
| Nurses gather data about how the patient’s body is functioning using the following techniques: | inspection ,palpation ,auscultation ,percussion |
| a medical diagnosis is a label for | a disease, illness, or injury, such as coronary artery disease, pneumonia, or hematoma. |
| A nursing diagnosis, however, is a | label or statement for a problem that a patient is experiencing as a result of the medical diagnoses |
| This type of diagnosis is treated by the nurse using interventions to improve the patient’s ability to function as normally as possible. | A nursing diagnosis |
| Nursing diagnoses address | physical, psychosocial, and environmental needs of patients, with some of them being a higher priority than others |
| How do nurses decide which diagnoses are the most important? | Maslow’s Hierarchy of Human Needs. |
| The first level of maslow’s Hierarchy of Human Needs | physiological needs- needs to survive |
| 2nd leval maslows | physiological needs-those things a human being needs to remain alive and protected |
| third level maslows | includes the need for love and belonging, such as meaningful relationships |
| 4th leval maslows | is the need for self-esteem and feelings of self-worth. |
| 5th lval maslows | that addresses cognitive needs for learning and exploring |
| sixth level maslows | composed of aesthetic needs for beauty and order. |
| The seventh level maslows | addresses the need for self-actualization, which is the need for reaching one’s own growth potential, and the highest level is that of transcendence, or the need to help others reach their highest potentia |
| NANDA-I, which stands for North American Nursing Diagnosis Association International, is responsible for | creating and maintaining an approved list of nursing diagnoses to be used throughout most countries, including the United States and Canada. |
| nanda purpose | -By establishing and revising this list, nursing diagnoses are standardized for use by nurses everywhere and lend themselves more easily to computerized documentation than individually developed diagnoses. |
| defining characteristics is | signs and symptoms, exhibited by the patient. |
| The three-part statements are often called PES statements | This stands for problem, etiology, and signs and symptoms |
| The problem is the | diagnostic concept or label based on the patients’ needs. |
| The etiology refers to the | causative factor(s) and is connected to the diagnostic label by the words “related to.” |
| The signs and symptoms | include the data collected and the evidence used to support the diagnostic label. They are linked to the statement with the words “as evidenced by.” |
| a PE statement, or problem and etiology only | When the nursing diagnosis is one that expresses the risk for a problem, a possible problem, or certain actual problems, the two-part statement is used |
| NANDA-I diagnosis falls into the category of “wellness,” “syndrome,” or “specified,” a | one-part statement is used. |
| nanda I | wellness, syndrome or specified need |
| Planning | setting long-term and short-term goals, planning outcomes for each nursing diagnosis, and planning the interventions you will use in the implementation step. |
| A nursing goal is | the overall direction in which one must progress to improve a problem. |
| Expected outcomes are | statements of measurable action for the patient within a specific time frame and in response to nursing interventions. |
| Outcomes statements should include the following information: | A realistic, specific action to be taken by the patient (not the nurse): An action that the patient is willing and able to perform: An action that is measurable A definite time frame for the action to have been accomplished |
| discharge criteria | expected outcomes are often required before a patient can be discharged from the hospital |
| Nursing actions, or interventions, are sometimes referred to as | nursing orders |
| Direct patient care is | is performed when the nurse interacts directly with the patient. |
| Indirect patient care is | performed when the nurse provides assistance in a setting other than with the patient. |
| independent interventions | When nurses determine that interventions are needed, they may be able to provide the intervention without consulting anyone else |
| dependent interventions. | Some nursing interventions do require a health-care provider’s order before they can be performed; |
| Collaborative interventions | are those that involve working with other health-care professionals in the hospital setting, |
| When nurses take their critical thinking and turn it into nursing actions, it is known a | clinical judgment |
Created by:
mmishue