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Foundations Exam 1

Nursing 204

Step one of assessment collection and verification of data from primary sources and secondary sources
Step two of assessment the analysis of all data as a basis for developing a plan of individualized care
What is a cue? information you obtain through senses
What is an inference? your judgement or interpretation of the cues
What is the orientation phase of an interview? introduce yourself and the role of you and other establish a caring therapeutic relationships
What is the working phase of an interview? gather information about the client's health status; this is when health history is done
What is the termination phase of an interview? give your client a clue that the interview is ending, summarize important points and ask client if summary was accurate
what is an actual nursing diagnosis? describes human responses to health conditions or life processes that exists in an individual, family, or community
What is a risk nursing diagnosis? describes human responses to health conditions/life processes that will possibly develop in a vulnerable individual, family, or community
What is a health promotion diagnosis? a clinical judgement of a person's, family's, or community's motivation and desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors
What is a wellness nursing diagnosis? describes human responses to levels of wellness and individual, family, or community that have a readiness for enhancement
What is the diagnosis label? name of the nursing diagnosis as approved by NANDA-I; describes the essence of patient's condition
What are related factors? a condition or etiology identified from the client's assessment data related to client's response to health problem and can change by using nursing intervention
What are the definitions in a diagnosis? describes the characteristics of the human response indentified
What is initial planning? Initiated ASAP following the assessment by the same nurse
What is ongoing planning? Performed by all nurses who work with the client
What is discharge planning? Process of anticipating and planning for needs post discharge
What is considered HIGH priority? Diagnoses, that if left untreated, could result in harm to the patient
What is considered INTERMEDIATE priority? diagnoses that involve non-emergent, non-life threatening needs of clients
What is considered LOW priority? client needs which may not be directly related to a specific illness but may affect future well-being; long term health goals
What is the purpose of Goal-directed Care? client goals describe what the nurse hopes to achieve by implementing the nursing orders
What are the 5 parts to a client GOAL? subject, task statement, criteria, condition, time frame
What is a broad goal? One big goal that the client will complete over a longer period of time
What is a short term goal? A goal that can be completed in a short period of time (Hours, days, less than a week)
What is a long term goal? A goal that may take the client several weeks, months, etc. to complete
What are expected outcomes? a specific, measurable change in a client's status that is expected to occur in response to nursing care
What are the 7 guidelines for outcomes? Client centered, singular goal, observable, measurable, time-limited, mutually set, realistic
What is a nursing intervention? an action performed by a nurse that helps the client achieve the results specified by the goals and expected outcomes
What is a nursing order? A statement written by the nurse that is within the realm of nursing practice to plan and initiate
What are nurse-initiated interventions? independent response of the nurse to the client's healthcare needs and his nursing diagnoses
What are physician-initiated interventions? dependent actions based on physician's response to treat or manage the medical diagnosis
What are collaborative nursing interventions? inderdependent actions which require the knowledge, skills and expertise of multiple healthcare professionals
What are the different types of nursing orders? Observation, prevention, treatment, health promotion
What are the 6 components needed for a nursing order? 1. date 2. subject not written 3. action verb 4. descriptive qualifiers 5. specific times 6. signature/initials
What is the purpose of a rationale for interventions? reason for a particular intervention based on theories and scientific principles; not used in professional nursing
What is a Direct Care nursing intervention? performed through interactions with client; ex. med pass, vitals, teaching...
What is an Indirect Care nursing intervention? treatments performed away from the client but for the client; ex. collaborating, charting, referring...
What is a protocol? a written plan specifying procedures to follow during the care of clients with a select clinical condition or situation
what is a standing order? a pre-printed document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures
what are care maps/critical pathways? a set of orders that are evidence based and have been preapproved for a specific type of patient
What does it mean if a hospital has magnet recognition? Program to recognize nursing services that build programs to excellence for delivery of nursing care, promote quality in environments that support professional nursing practice and promote achievements of positive client outcomes
What is Team Nursing? began after WWII, RN is team leader, RN spends little time with client, members of team work together
What is Primary Nursing? Puts RN at bedside, nurse-client relationship strong, RN selects caseload, provides continuity of care
What is Total Patient Care? RN is responsible fore all aspects of patient care but can delegate, shift-based focus, used when RNs were plentiful
What is Case Management? coordinates & links healthcare services to clients, streamlines costs and maintains quality, manage specific diagnoses or complex illness wherever patient is
Quality Improvement Model: Structure? Ability to provide services; ex. physical facilities, resources...
Quality Improvement Model: Process? measurement of nursing actions by examining each phase of the nursing process; ex. policies/procedures
Quality Improvement Model: Outcome? process of comparing the client's current status with expected outcomes; client knowledge, self care abilities...
What is a nursing audit? Collecting and analyzing data to determine the effectiveness of nursing interventions
What is JCAHO? Joint Commission on Accreditation of Healthcare Organizations; integrate outcomes and performance into accreditation
What is NCQA? National Committee for Quality Assurance; non profit accreditation for managed care (insurance)
Created by: 607761034