Unit 2: Nursing Process UALR
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| Critical Thinking | discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches for dealing with client care and professional concerns.
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| Critical Analysis | the application of a set of questions to a particular problem or situation to determine essential information and ideas.
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| Nursing Process | a systematic, rational method of planning and providing individualized healthcare.
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| A.D.P.I.E. | Assess; Diagnose; Plan; Implement; Evaluate
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| Four points of Assessment (COVD) | Collect Data; Organize Data; Validate Data; Document Data
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| Three steps of Diagnosing (AIF) | Analyze Data; Identify health problems, risk, & strengths; Formulate diagnostic statements
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| Four parts of Planning (PFSW) | Prioritize problems, Formulate goals; Select interventions; Write interventions
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| Five components of Implementing (RDISD) | Reassess the client; Determine nurses need for assistance; Implement the intervention; Supervise delegated care; Document nursing activities
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| Five points of Evaluation (CCRDC) | Collect data related to outcomes; Compare data with outcomes; Relate nursing actions to client goals; Draw conclusions about problem status; Continue, modify or terminate plan
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| Name four types of assessment (IPET) | Initial; Problem-focused; Emergency; Time-lapsed
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| Nine components of a Nursing Health History | Biographical data; Chief complaint; History of present illness; History of past illnesses; History of family illness; Lifestyle; Social data; Psychological data; Patterns of healthcare
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| What is subjective data | Data that cannot be observed.
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| What is objective data? | Observable data.
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| Name sources of client data. | The Client; Support people, i.e. family, friends, and caregivers; Client records; Health care professionals; Literature
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| What are three methods of collecting data? | Observing; Interviewing; Examining
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| Name two types of interviewing methods. | Directive and non-directive
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| What is a directive interview? | A highly structured session that elicits specific information in a set amount of time.
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| Describe the purpose of a non-directive interview. | This is the rapport building session usually allowing the client to control the purpose, pace and subject matter.
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| List four types of interview questions. | Closed; Open-ended; Neutral; Leading
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| Elements of a physical exam | Vital Signs; H&W; Cephalocaudal exam; Body systems review
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| Four methods of examination | Inspection; Palpation; Percussion; Ascultation
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| Define Palpation | The process of feeling and lightly touching the skin to check for abnormalities.
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| What is ascultation? | Listening to internal functions with a stethoscope.
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| What is nursing diagnosis? | Using critical thinking to identify health patterns.
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| List the eight basic biophysical needs. (OFSNECRS) | 1)Oxygenation; 2)Fluids/Electrolytes; 3)Safety; 4)Nutrition; 5)Elimination; 6)Comfort; 7)Rest/Activity; 8)Sensory
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| List the four basic psychosocial needs. (LHSS) | 1)Learning; 2)Human interaction; 3)Sexuality; 4)Spirituality
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| Name five types of nursing diagnosis in order of importance. | Actual, Risk, Possible, Syndrome, and Wellness
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| What are the two component of a nursing diagnosis? | The problem and the etiology.
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| Define etiology. | Etiology is the explanation of why a problem exist.
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| What governing body outlines nursing diagnosis? | North American Nursing Diagnosis Association (NANDA)
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| What phrase is commonly used to in the ND to identify the etiology? | Related to; R/T
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| List three types of planning. | Initial; on-going; discharge
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| When do you start discharge planning? | Upon admission.
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| Names two types of care planning. | Standardized and Individual
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| Identify criteria for setting goals. | Patient-centered; mutually set; singular/specific; observable; measurable; time-limited and realistic
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| Four stages of nursing interventions. | Selecting; Prioritizing; Implementing; Evaluating
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| Components of an intervention statement. | Subject, action, criteria, special conditions, and time constraint.
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| The difference in short term and long term goals would be what? | Short-term goals would be less than one week. Long-term goals would be longer than one week.
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| Every intervention must be accompanied by what? | A rationale that supports the goals of the intervention.
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| What is NIC? | Nursing Intervention Classification which is linked to NANDA nursing diagnosis data.
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| How is NIC useful to nurses? | NIC outlines possible interventions linked to defined diagnosis.
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| Why is it important to use NIC taxonomy? | To insure the proper intervention is used supporting the rationale for implementing the action.
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| What is NOC? | Nursing Outcomes Classification used for defining outcomes related to interventions.
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| What are the 5 rights to delegation? (TCPDS) | Task; Circumstance; Person; Direction; Supervision
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| How do you generate good nursing interventions and rationales? | review diagnosis; review desired outcomes; identify possibilities; choose the most appropriate; individualize to the client.
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| What is Source-Oriented Documentation? | This is a chart where each department has a section for their particular charting needs and methods. ASH uses this method.
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| What is POMR? | This stands for problem-oriented medical record and arranges data in order regarding client problems. Doctors offices uses this.
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| What does SOAP stand for? | Subjective data; Objective data; Assessment; Plan
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| What is PIE charting? | This refers to a charting method that identifies the problem, the intervention and the evaluation. Usually involves a flow sheet and progress notes.
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| What is DAR charting? | Refers to Data, Action and Response. very similar to PIE charting.
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| What is charting by exception? | This type of charting establishes acceptable parameters then chart is done based on any abnormalities in relation to those guidelines.
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| What is a COW? | Computer On Wheels; used in some institutions to maintain client records.
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| What abbreviations are unacceptable in charting? | U,u,IU,QD,QoD,MS,MSO4,MgSO4, trailing and leading zeros
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