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RN Test 1

RN program test 1

define nursing process critical thinking competency that allows nurses to make judgements and take actions
5 steps of nursing process assessment, nursing diagnosis, identification of expected outcomes and planning, implementation, evaluation
define outcome identification and planning establish goals and plan of care to meet needs
define implement deliver care established by plan
what are the parts of Assessment Systematically collecting, verifying, analyzing, and communicating data about client.
give examples of subjective data clients perception - pain, anxiety, discomfort, stress. Obtained in interview, can be difficult to measure (dizziness, nausea, pain, burning on urination)
examples of objective data observations or MEASUREMENTS made by the nurse, physical exam, lab data, medical records. (BP, Temp, Pulse, X-rays, Lab values)
6 steps of the Assessment collect data, organize/cluster data, validate data, record, look for patterns, make "impressions"
define nursing diagnosis Statement of potential or actual altered health status of client which is derived from nursing assessment and which requires interventions from the domain of nursing.
the _____ list has the approved nursing diagnoses NANDA
what is the difference between a Nursing Diagnosis and Medical Diagnosis Purpose, goals, therapeutic intervention
5 types of nursing diagnosis actual, risk, possible, syndrome, wellness
type of diagnosis that the person's database contains evidence of signs and symptoms or defining characteristics of the diagnosis actual diagnosis
define a risk/potential diagnosis person's database contains evidence of the related factors of the diagnosis but no evidence of the defining characteristics
define possible diagnosis person's database does not demonstrate the defining characteristics or related factors of the diagnosis but your intuition tells you the diagnosis may be present
what is the purpose of the goals r/t nursing diagnoses? Provide individualized care Promote client participation Plan care that is realistic and measurable Allow for involvement of support people
what three things must the goal have r/t a nursing diagnosis Goal must have: Subject (patient) Verb (action patient will perform) Criteria (expected behavior – measurable)
examples of verbs used for goals r/t a nursing diagnosis Define Identify List Describe Explain Apply Prepare design Verbalize Choose Select Demonstrate
define nursing interventions any tx based on clinical judgement that a nurse performs to enhance patient outcomes.
what are the three types of nursing interventions? Nurse initiated (independent) Interdependent (collaborative) Physician initiated (dependent)
examples of nursing interventions daily care complex physiologic care behavioral safety family health systems
which phase does the plan of care developed? OUTCOME/PLANNING
which phase do you document what you have done r/t interventions? Implementation - Do it & document
the process of collecting, organizing, validating, and recording data about a client's health status. Assessment
a collegial working relationship with another health care provider in the provision of client care. collaboration
two way process involving the sending and receiving of information communication
change in human disposition of capability that persists over a period of time and cannot be solely accounted for by growth. learning
method of organizing care delivery that emphasizes communication and coordination of acre among all health care team members managed care
a set of attributes that implies responsibility and commitment professionalism
set of expectations about how a person occupying a specific position behaves Role
clash between the beliefs or behaviors imposed by two or more roles fulfilled by one person role conflict
system of activities designed to produce learning teaching
who wrote and what is the name of the dissertaion that proposed a 2-year education program for RNs in community colleges? Mildred Montag published "The Education of Nursing Technicians"
where was the first ADN program? Columbia University Teacher's College
where was the first BSN program? University of Minnesota
nurses provide care for three types of clients, name them individuals, families, and communities
what are the four areas nursing practice involves? promoting health and wellness, preventing illness, restoring health, and caring for the dying
what is the purposes of the ANA? foster high standards of nursing practice and to promote the educational and professional advancement of nurses
purpose of NLN foster the development and improvement of all nursing services and nursing education.
graphic illustration of the relationships among concepts conceptual method
a piece of information or data that influences decisions cues
all information of a client/pt that includes nursing health hx, physical assessment, PE, lab and diagnostic test results database
client s/s that must be present to validate a nursing diagnosis defining characteristics
statement or conclusion concerning the nature of some phenomenon diagnosis
causal relationship between a problem and its related or risk factors etiology
planned ongoing purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes evaluate
what the nurse hopes to achieve by implementing the nursing interventions goals/outcomes
phase of nursing process in which the nursing care plan is put into action Implement
interpretations or conclusions made based on cues or observed data inferences
nurse's clinical judgement about individual, family, or community responses to actual and potential health problems/life processes to provide the basis for selecting nursing interventions nursing diagnosis
tx based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes interventions
systematic rational method of planning and providing nursing care nursing process
this information can be quantified, tested against a standard, can be seen, felt, heard, or smelled objective data
process that involvesassessing a situation, establishing goals and objectives, developing a plan of action that sets priorities, who is responsible, deadlines, and how the outcome will be achieved plan/planning
any subjective evidence of a disease symptom
objective observations of a disease; example blood from the nose, abnormal lung sounds sign
things a pt tells you. example pain, nausea, intermittent cough subjective information
determination that the diagnosis accuratreflects the roblem of the client and that the methods used for data gathering were appropriate and diagnosis is justified by the data validation
part of the nursing process: interpret data, identify and communicate nursing diagnosis, determine health team's ablility to meet cllient's needs Diagnosing
part of the nursing process: Organize and manage the client's care, perform client care, delegating care, counsel, teach Implementation
part of the nursing process: gather objective and subjective information Assessment
part of the nursing process: determine and prioritize outcome of care. Develope and modify plan for delivery of client's care. Planning
part of the nursing process: Compare desired outcomes to actual outcomes. Record and describe client's response to plan. Evaluation
put the parts of the nursing diagnosis in order Assessing, Diagnosing, Planning, Implementing, Evaluating
how long does the RN have to complete the initial admission assessment? 24 hours
what are some examples of different aspects of the assessment process? client's own perspective on thier condition, communicatio barriers, impact of nurse's attitude, values, and beliefs, protection of privacy of data
objective/symptoms/covert data includes: itching, pain, feelings of worry - unmeasureable things.
objective/signs/overt data includes: Vital signs, heart sounds, lung sounds - things you can hear, touch, and measure..ect
who is the primary source of data? The patient
examples of secondary data include: family members, other health professionals, records, reports, lab data: all sources other than the pt.
name the portions of the Nurse Health Hx biographic info, chief complaint, hx of present illness, PMH, Family Hx, lifestyle, Social data, psych data, patterns of health care
a collection of people who share some attribute of thier lives community
nursing care directed toward a specific population or group within the community, primary, secondary, or tertiary care may be provided to individuals or groups Community-based nursing (CBN)
the synthesis of nursing and public health practice as applied to promoting and preserving the health of populations Community health nursing
activities directed toward the protection from or avoidance of potential health risks. primary prevention
activities designed for early diagnosis and tx of disease or illness secondary prevention
activities designed to restore individuals with disabilities to their optimal level of functioning. tertiary prevention
Created by: jrstrader