Nursing Process- Potter and Perry 7th Edition
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| show | Nursing Process
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| show | Nursing Assessment
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| show | Database
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| Sources of obtaining data for Nursing Assessment: | show 🗑
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| 3 Phases of Assessment Interview: | show 🗑
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| show | Open Ended Questions
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| This limits the client's answers to one or two words such as "yes" and "no" or a number or frequency of a symptom. | show 🗑
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| show | Subjective Data
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| This is nurse observed data. | show 🗑
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| show | 1)Assessment,2)Diagnosis,3)Planning,4)Implementing,5)Evaluation.
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| Published in 1967. | show 🗑
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| Clinical judgment about client response to actual or potential problem based on data collected during assessment. This provides basis for selecting nursing interventions to achieve outcomes. May change frequently. | show 🗑
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| show | Collaborative Problem
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| Clusters and patterns of data contain this, a critical criteria or assessment findings that support an actual nursing diagnosis. Contains subjective and objective data. | show 🗑
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| show | 1)Observation- what you see. 2)Auscultation- listening with or without stethoscope.3)Palpation- feeling with fingers.4)Percussion
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| show | Clinical Criteria
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| Describes human responses to health conditions/ life processes that will possibly develop in a vulnerable individual, family or community. | show 🗑
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| show | Wellness Nursing Diagnosis
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| show | Diagnostic Label
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| show | Related Factor
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| The "why" of nursing diagnosis. Environmental or contributing factors. | show 🗑
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| show | 1)Specific Knowledge,2)Experience,3)Competencies,4)Attitudes,5)Standards.
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| 3 Basic Levels of Critical Thinking: | show 🗑
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| show | 1)Identify client's health needs,2)establish nursing care plan,3)complete interventions.
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| show | 1)Data interpretation and analysis,2)Reaching conclusion,3)Formulating the nursing diagnosis.
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| show | 1)Recognize significant data-compare to standards,2)Validate the data-recheck data, troubleshoot equipment, compare subjective and objective data, clarify patient statements with family or other staff.3)Recognize patterns or clusters.
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| 4 Types of Nursing Diagnosis: | show 🗑
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| Formulate diagnosis statement by using PES format. What does PES stand for? | show 🗑
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| show | PE
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| Utilizes the Nursing Diagnoses to determine the nursing action systems needed to formulate an individualized plan of care for the client to meet their needs. | show 🗑
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| show | goals/ outcomes,interventions/ nursing orders.
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| 5 reasons why there is a Planning Phase of Nursing Process: | show 🗑
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| The ordering of nursing diagnosis or client problems using notions of urgency and/ or importance to establish a preferential order for nursing actions. | show 🗑
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| show | 1)Initial- first patient contact.2)Ongoing- continuous to meet current needs.3)Discharge-extension of care after discharge.
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| Priorities are ranked as: | show 🗑
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| show | High Risk
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| show | Medium Risk
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| show | Low Risk
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| show | Goal
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| This is the desired results of actions taken to achieve a broader goal, measurable steps toward achieving the desired results, multiple coutcomes in a goal, complete sentence not necessary (verb, criteria, time) | show 🗑
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| show | A Nursing Diagnosis
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| Patient will walk unassisted with crutches by discharge. This is an example of? | show 🗑
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| show | Outcomes
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| show | 1) Short term goal. 2) Long term goal.
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| show | Considering what the client is willing to do or can do.
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| A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. | show 🗑
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| Interventions are derived from this statement of the nursing diagnosis. | show 🗑
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| show | Interventions
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| 3 Types of Interventions of Nursing Process: | show 🗑
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| This enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. | show 🗑
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| show | 1)What is the intervention?2)When should each intervention be implemented?3)How should the intervention be performed for this specific client?4)Who should be involved in each aspect of intervention?
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| Nursing Interventions should be these 4 C's: | show 🗑
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| show | 1)Clear and concise described action.2)Use accepted abbreviations only.3)Dated when written.4)Signed by initiating nurse.
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| show | 1)Assessments- type, frequency.2)Direct Care Measures-instructs direct care staff of completing intervention.3)Teaching-instructs patient to use or educates.4)Counseling 5)Advocacy-speaks for client.
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| Types of Care Plans | show 🗑
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| This step of nursing process formally begins after the nurse develops a plan of care. It is the treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/ client outcomes. | show 🗑
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| show | Clinical guidelines or Protocol
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| show | Standing order
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| This system developed by the University of Iowa helps to differentiate nursing practice from that of other health care professionals. | show 🗑
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| show | NIC Interventions
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| show | ADL (Activities of Daily Living)
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| show | IADL (Instrumental Activities of Daily Living)
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| This part of the nursing process determines if after application of the nursing process the client's condition or well- being improves. | show 🗑
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| show | 1)Identifing criteria- goals and outcomes.2)Collect evaluative data.3)Interpreting and summarize.
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| After Evaluation, a nurse makes these decisions: | show 🗑
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| show | 1)Quality Improvement (CQI,TQM)2)Quality Assurance (QA)3)Outcomes Management4)Nursing Audit5)Self-Evaluation
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| The transfer of responsibility for the performance of an activity from one individual to another while still retaining accountability for the outcome. | show 🗑
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| show | 1)Assessment2)Planning3)Evaluation4)Nursing judgement
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| show | 1)Right task.2)Under right circumstances.3)To right person.4)With right directions and communication.5)Under the right supervision and evaluation.
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| show | 1)Verbal2)Written
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