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VNSG 1400 Exam 1
Nursing in Health and Illness
| Question | Answer |
|---|---|
| A way of thinking and acting based on the scientific method | the nursing process |
| coverting info and establishing a care plan for each patient | process |
| Five components of the nursing process | Assessment, nursing diagnosis, planning, implementation, and evaluation |
| Assessment (data collection) | careful observation and evaluation of a patient's health status |
| Nursing diagnosis | identify actual or potential health problems |
| Prioritize problems, identify goals and document plan | planning |
| carry out nursing orders | implementation |
| evaluate care given | evaluation |
| Characteristics of nursing process | goals, prioritized, and dynamic |
| directed the nurse and the patient work together to achieve set goals | Goals |
| focused care resolves the health problems with the greatest risk first | Prioritize |
| always changing as the patient changes | Dynamic |
| Organize your data by | body systems |
| Signs | Vital signs, anything that can be measured |
| Symptoms | information that only the patient feels and can describe |
| Objective Data | Signs |
| Subjective Data | Symptoms |
| Breathing, how is the patient feeling, appearance, affect(mood), skin color | Initial observation |
| Level of consciousness, able to communicate, mental status, and appearance of eyes | Head |
| Temp, pulse, respirations, and blood pressure | Vital Signs |
| Listen to front and back | Auscultation lungs |
| Listen to lub-dub sounds S1 and S2 | Auscultation of heart |
| shape, soft or hard, appetite, last BM, voiding status | Abdomen |
| Always look first, listen to all four quadrants, then feel | auscultation of bowel sounds |
| To legally chart no bowel sounds you must listen to each quadrant for how many minutes | five |
| Normal movement, skin turgor, temp, peripheral pulses, edema, cap refill | Extremities |
| The nursing diagnosis includes three parts | the name and cause of the problem, and the s/s |
| Collaborative problems are | potential complications |
| Nursing diagnosis defines | the patients response to illness |
| Medical diagnosis | labels the illness |
| NANDA identifies five types of nursing diagnosis | Actual, Risk, possible, syndrome, and wellness |
| Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures | Nursing Diagnosis |
| a problem that currently exist | Actual |
| a problem the patient is uniquely at risk of developing | Risk |
| a problem may be present, but requires more data collection to rule out or confirm its existence | Possible |
| What two types of nursing diagnosis must include the problem, cause and s/s | Actual and Risk |
| cluster of problems predicted to be present because of an event of situation | Syndrome |
| a health related problem that the patient initiates with which a healthy person obtains nursing assistance to maintain or perform at a higher level | Wellness |
| placing nursing diagnosis/interventions in order of importance | Priority setting |
| life threatening problems | high priority |
| problems that threaten health or coping ability | Medium priority |
| problems that do not have a major effect on the person if not attended to that day or week | Low priority |
| the process of prioritizing nursing diagnosis and collaborative problems, identifying measurable goals and outcomes | Planning |
| while developing and revising the plan the nurse must | consult with the patient |
| a broad idea of what is to be achieved through nursing interventions | Goal |
| are those that are achievable within 7-10 days or before discharge | Short term goals |
| goals that take weeks or months to achieve | long term goals |
| are derived from the goals | expected outcomes |
| should also contain measurable criteria that can be evaluated to see whether the outcome has been achieved | expected outcomes |
| an expected outcome should be realistic and attainable and should | have a defined time line |
| Specific, Measurable, Attainable, realistic, and timed | SMART |
| state goals in a way that spells out the end result you want to achieve | Specific |
| how will you know when you have met your goal | Measurable |
| can the goal be met as stated | Attainable |
| can you reasonably expect to achieve your goal | Realistic |
| set a time frame for accomplishment and re-evaluation of your goal | Timed |
| planning the measures that the client and nurse will use to accomplish identified goals involves | critical thinking |
| are directed at eliminating etiologies | Nursing interventions |
| must be safe, within legal scope of practice, and compatible with medical orders | Nursing interventions |
| a concept of reason | Rational |
| all nursing interventions require a | scientific rational |
| can be hand written, standardized, computer generated, or based on an agency's written standards or clinical pathways | Plan of care |
| the plan of care should be reviewed and updated | once every 24 hours |
| the nurse shares the plan of care with | nursing team members, the client, and clients family |
| carrying out the written plan of care, performing the interventions, monitoring the patient's status and assessing and reassessing the client | Implementation |
| independent nursing diagnosis | needs no physicians order |
| dependent nursing diagnosis | needs a physicians order |
| deciding whether the interventions have helped the patient | Evaluation |
| it is the analysis of the client's response, evaluation helps determine the effectiveness of nursing care | Evaluation |
| if goals are not reached | the plan must be revised |
| will make nurses more efficient and effective at resolving situations | developing good critical thinking skills |
| a key feature is the ability to maintain a questioning attitude | Critical thinking |
Created by:
nursekk
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