2 Fundamentals - Nursing Process

Front 1

subjective and objective data on a patientto collect and examine info to get facts to determine pt health status and strengths and weaknesses

Back 1

nursing process

Front 2

assessment upon admission

Back 2

initial assessment (head to toe)

Front 3

assessing specific problem identified

Back 3

focused assessmenet

Front 4

physiplogic or psychologic crisis (ER)

Back 4

emergency asssement

Front 5

compare to baseline assessment

Back 5

time-lapsed assessment

Front 6

the primary source of data is

Back 6

the patient

Front 7

the secondary source of data is

Back 7

family, patient record, med history, labs

Front 8

determining the pt current respoonses, ability to manage care, immediate environement and safety

Back 8

observation PART 1

Front 9

In the second part of nursing process you have the ___________

Back 9

interview

Front 10

the 4 skills to assessment are

Back 10

insepction (eyes)
ausculation (Ears)
palpation (touch)
percussion

Front 11

a goal of data validation is to prevent

Back 11

error, bias, misrepressentation

Front 12

when do you verify?

Back 12

when there is discrepency between what person is saying and what nurse is observing

when data LACKS objectivity!

Front 13

information one aquires through observation using the 5 senses is called

Back 13

CUE

ex) elevated BP

Front 14

NURSES Judgement or interpretation of cues is called

Back 14

INFERENCE

Ex) why is bp up!

Front 15

You must establish __________ and cluster data... more than 1 nursing diagnosis means you must establish this.

Back 15

PRIORITY!

Front 16

enter intiital database into computer or record in ink same day patient is admitted.

summarize obj and subj data in concise, comprehensive, easily retreivable manner

Back 16

use good grammer, standard med anbbreviations

whenever possible, use pts own words.

avoid non specific terms.

YOU MUST COMMUNICATE ABNORMAL RESULTS AND WHAT YOU DID WITH THEM

Front 17

when assessment phase is complete and date collection is complete, the next phase of the nursing process is_________

Back 17

DIAGNOSIS

Front 18

Purposes of the DIAGNOSING step are

Back 18

ID how an individual responds to actual or potential health and life processes.

ID factosr controible to or cause health problems

ID resources or strengths the individual can draw on to prevent or resolve problems

Front 19

a coniditon that needs intervention to prevent or resolve disease or promote well being is called a

Back 19

health problem

Front 20

an ACTUAL or POTENTIAL health problem that can be prevented or reslolved by indepdnant nursing interventions.

same as patient problem

Back 20

nursing diagnosis

Front 21

what you see present at the time you do your assessment

"pt is fatigued"

Back 21

ACTUAL problem

Front 22

At Risk for ..... ex) bed sores

Back 22

POTENTIAL problem

Front 23

the only two problems a nurse can act on is ...

Back 23

ACTUAL / AT RISK (potential)

Front 24

a problem that needs more data to see if actual or at risk for a problem is known as a

Back 24

POSSIBLE problem

Front 25

labels or patint problems to select intervention is given by

Back 25

NANDA
north american nursing dx assoc

Front 26

what describes problems for which the physician directs primary treatment

identify diseaess - remain the same for as long as disease is present - based on evaluation of physical symptoms, history, test, procedures

Back 26

medical diagnosis

Front 27

what describes pt problems nurses can treat indeopendantly

focuses on unhealthy response to health and illness. problems terated within scope of nurse practice.

changes day to day as patients responds to change.

Back 27

RN diagnosis

Front 28

managed by using physician prescribed and nursing prescribed interventions

Back 28

collaborative problems

Front 29

certain physiological complications that nurses monitor to detect a change in status, managed by physician, prescribed by MD and RN

Back 29

Collborative problems

Front 30

FOUR STEPS OF DATA INTERPRETATION

Back 30

1- Recognize significant data (CUES) compare to standards

2- recognize patterns or clusters

3. ID strenghts and problems by the RN

4- reach conclusion

Front 31

What type of problem needs MORE DATA

Back 31

POSSIBLE PROBLEM

Front 32

What type of problem is "at risk for"

Back 32

POTENTIAL PROBLEM

Front 33

A predicted event that the nurse already has proven info for, not necessary to collect data, just react. is called a

Back 33

SYNDROME

Front 34

3 MOST IMPORTANT TYPES OF NURSING DIAGNOSES

Back 34

ACTUAL - saw prob
@ RISK - saw pt, id risk
POSSIBLE - neeed more info

Front 35

3 PARTS OF WRITING RN DIAGNOSIS

Back 35

1 - PROBLEM
2- CAUSE/ETIOLOGY
3- AS MANIFESTED BY (subjective/objective data)

Front 36

2 PART EXAMPLE

Back 36

CONSTIPATION (PROB)
RELATED TO INADEQUATEINTAKE OF HIGH FIBER FOODS (ETIOLOGY)

Front 37

3 PART EXAMPLE

Back 37

CONSTIPATION (PROB)
RELATED TO INADEQUATEINTAKE OF HIGH FIBER FOODS (ETIOLOGY)
AS MANIFESTED BY ABDOMINAL PAIN AND INABILITY TO HAVE A BM SINCE SURGERY (DEFINING CHARACTERISTICS)

Front 38

COMMON SOURCES OF ERROR IN DIAGNOSING

Back 38

premature diagnosis based on incomplete database

failure to tailor data to pt

ommission

Front 39

UNIVERSAL BENEFIT OF RN DIAGNOSES

Back 39

individualized pt care
defining domain of rn to healthcare administrators, legislators

seeking funding for nursing reimbursement

facilate communication among rn and other hc members

help nurse focus on independant rn actions

Front 40

step 1 - cluster data
step 2 - problem? possible? actual
step 3 - write diagnosis

Back 40

:)

Front 41

goal of PLANNING

Back 41

to communicate prescribed interventions and establish pt goals
and pt outcomes.

select evidenced based RN intervention

Front 42

Expected conclusion to a PT problem is known as

Back 42

outcome

Front 43

refers to meausrable criteria to see if goal is met

Back 43

expected outcome

Front 44

WHAT STEP DO YOU WRITE A PLAN OF CARE FOR ?

Back 44

PLANNING

Front 45

stage of planning by the nurse who performs the nursing history and assessment

addresses each prob listed in the prioritized nursing diagnosis

ID appropriate pt goals and related rn care

Back 45

INITIAL PLANNING

Front 46

carried out by any nurse interacting w/ patient...keeps plan up to date...states rn diagnosis more clearly...ID nursing interventions and goals and establishes new diagnosis

Back 46

ONGOING PLANNING

Front 47

carried out by the nurse who worked most closely with patient, BEGINS WHEN THE PT IS ADMITTED TO TREATMENT...uses teaching and counseling skills to sensure home-care behaviors performed competently.

Back 47

DISCHARGE PLANNING

Front 48

greatest threat to pt well being is the highest _______

Back 48

priority

Front 49

non threatening diagnoses are _______ priority

Back 49

mediumj

Front 50

diagnose not specifically related to current problem is_________ priority

Back 50

low

Front 51

3 ways to help with PRIORITIZING

Back 51

MASLOWS HIERARCHY (291)

PT PREFERENCE

ANTICIAPTION OF FUTURE PROBLEMS

Front 52

3 ways to help with PRIORITIZING

Back 52

MASLOWS HIERARCHY (291)

PT PREFERENCE

ANTICIAPTION OF FUTURE PROBLEMS

Front 53

requires a longer period to be achieved and may be used as discharge goals

Back 53

long term outcomes/goals

Front 54

requires a longer period to be achieved and may be used as discharge goals

Back 54

long term outcomes/goals

Front 55

may be accomplished in specific period of time, steppeing stone to long term goal

Back 55

short term goal outcome

Front 56

may be accomplished in specific period of time, steppeing stone to long term goal

Back 56

short term goal outcome

Front 57

a category of outcome describing increase in pt knowledge

Back 57

COGNITIVE

Front 58

a category of outcome describing increase in pt knowledge

Back 58

COGNITIVE

Front 59

a categry of outcome describing through physical action, new skills

Back 59

PSYCHOMOTOR

Front 60

a categry of outcome describing through physical action, new skills

Back 60

PSYCHOMOTOR

Front 61

a category of outcome describing chagnes in patient values, beliefs attitudes

Back 61

AFFECTIVE

Front 62

a category of outcome describing chagnes in patient values, beliefs attitudes

Back 62

AFFECTIVE

Front 63

a category of outcome describing physucal change in pt

Back 63

PHYSIOLOGIC

Front 64

a patient that can verbaklize info is in the cognitive category

a pt that can give himself insulin is in the

Back 64

PSYCHOMOTOR

Front 65

a category of outcome describing physucal change in pt

Back 65

PHYSIOLOGIC

Front 66

a patient that can verbaklize info is in the cognitive category

a pt that can give himself insulin is in the

Back 66

PSYCHOMOTOR

Front 67

90 PERCENT of the time what is the subject in an outcome

Back 67

PATIENT

Front 68

verb that teaches, discuss, id , describe is known as

Back 68

cognitive verbs

Front 69

90 PERCENT of the time what is the subject in an outcome

Back 69

PATIENT

Front 70

verb that teaches, discuss, id , describe is known as

Back 70

cognitive verbs

Front 71

3 ways to help with PRIORITIZING

Back 71

MASLOWS HIERARCHY (291)

PT PREFERENCE

ANTICIAPTION OF FUTURE PROBLEMS

Front 72

requires a longer period to be achieved and may be used as discharge goals

Back 72

long term outcomes/goals

Front 73

may be accomplished in specific period of time, steppeing stone to long term goal

Back 73

short term goal outcome

Front 74

a category of outcome describing increase in pt knowledge

Back 74

COGNITIVE

Front 75

a categry of outcome describing through physical action, new skills

Back 75

PSYCHOMOTOR

Front 76

a category of outcome describing chagnes in patient values, beliefs attitudes

Back 76

AFFECTIVE

Front 77

a category of outcome describing physucal change in pt

Back 77

PHYSIOLOGIC

Front 78

a patient that can verbaklize info is in the cognitive category

a pt that can give himself insulin is in the

Back 78

PSYCHOMOTOR

Front 79

90 PERCENT of the time what is the subject in an outcome

Back 79

PATIENT

Front 80

verb that teaches, discuss, id , describe is known as

Back 80

cognitive verbs

Front 81

expressing sharing listening and communicating verbs are called

Back 81

affective

Front 82

pt will have a bm by 12 noon today is a

Back 82

short term goal

Front 83

a verb that is with demonstration, practive , walk , perform , action is a

Back 83

psychomotor verb

Front 84

pt will have self care huygiene met each shift is a _________ goal

Back 84

short term, psychomotor

Front 85

a pt will express relief of pain from a 10 to a 5 30 minute afer pain med is a ____ goal

Back 85

short term, affective goal

Front 86

gaining new pt knowledge is a

Back 86

cognitive goal

Front 87

outcomes for a pt are written upon________ and updated as needed to attain patient goals

Back 87

admission

Front 88

the second part of planning, where any action taken by the nurse to help the patient meet an expected outcome is met is called

Back 88

INTERVENTION

Front 89

3 TYPES OF INTERVENTION

Back 89

nurse initiated
md initiated
collaborative

Front 90

autonomous actions based on research that the nurse does to meet the patients goals..

do not need md order

monitor teach facilate, non invasive

Back 90

NURSE INTIATED INTERVENTION

Front 91

intervention initiated by MD carried out by nurse - the nurse is accountable for carrying out orders, must clarify if unsure

Back 91

physician initiated

Front 92

treatment initiated by other providers carried out by the nurse

Back 92

collaborate intervention

Front 93

assess type and level of pt pain is a

Back 93

nursing initiated intevention

Front 94

aminist prescribed drug to alleviate pain

Back 94

md initiated

Front 95

arrange for periods of uninterupted rest

Back 95

nurse initiated

Front 96

provide assistance devices such as long handled toothbrush

Back 96

collaborative

Front 97

administer laxative sand stool softeners as ordered

Back 97

physician

Front 98

a written guide that directs efforts of the nursing team as they work with patients to meet there health goals, mandiated by joint commision

Back 98

NURSING CARE PLAN

Front 99

TYPES OF NCP

Back 99

kardex, computer ncp,case management, concept map, student

Front 100

THE PRODUCT OF THE PLANNING STAGE IS THE

Back 100

NURSING CARE PLAN

Front 101

the summary of __________ is to estalish outcomes, goals that are meausrable.

long term./short term

the patients goal not nurses.

id interventions to meet the goals,
document the plan of care

Back 101

PLANNING

Front 102

to assist the pt in achieving health outcomes/goals through nursing interventions and to promote health, preven disease, facilioate coping with altered function and restore health is known as

Back 102

IMPLEMENTATION

Front 103

any action taken by the nurse to help pt move from a present state of health as decribed in the expected outcome.

done by implementing the nursing care plan

Back 103

RN INTERVENTION

Front 104

the ACTION PHASE of nursing prcess in which RN care is provided and the NURSING CARE PLAN PUT INTO ACTION

Back 104

IMPLEMENTATION

Front 105

writing nursing interventions is known as

Back 105

PLANNING

Front 106

doing nursing interventions is known as

Back 106

IMPLEMENTING

Front 107

steps of implemetnation

Back 107

assess and reassess
clarify pre-req rn skills
organize resources
promote self care
assist pt to meet goals
document

Front 108

pt cond is ever changing, asses prior to implementing an intervention and reassess after

Back 108

ASSESS AND REASSESS

Front 109

Problem soliving, descicon making and criticcal thinking skills is known as

Back 109

intellectual cognitiive skills

Front 110

work with others, coordinate activies, great communicator, advocate , recognize non verbal signs shows what kind of skill

Back 110

interpersonal

Front 111

proper use of equiptment and safety practices are what kind of skill

Back 111

technical skills

Front 112

knwoing your role and standards of law are what kinda skill

Back 112

ethical legal skills

Front 113

non compliance reasons are

Back 113

lack of fam support
lack of understanding benefits
low value attached to outcomes
adverse physical and emo effects of treatment, inabiity to afford

Front 114

The transfer of resonsibikity for the performance of an activity from one individual to another while retaining accountability for outcome is known as

Back 114

DELEGATION

Front 115

RN CARE THAT SHOULD NNNNOOOOOTTTTTTT BE DELEGATED

Back 115

initial/ongoing assessment
determing RN diagnoses and plans and evaluations
supervision and education of rn personell
nursing intervention requiring pro nursing knolwecdge judgenment or skill

Front 116

5 RIGHTS OF DELEGATION

Back 116

RIGHT TASK
RIGHT CIRCUMSTANCE
RIGHT PERSON
RIGHT COMMUNICATION
RIGHT SUPERVISION

Front 117

Never perform a rn intervention until you know reason/rationale, the expected outcome, side effects and adverse effects

Back 117

reassess before determing status of problem

be aware of policies and rules of delegation

Front 118

measuring the pt response to nursing actions and pts progress towards achieving goals

measuring bw nurse, pt and other care takers

Back 118

EVALUATION

Front 119

judges each component of rn process.

evaluate goalachievement

Back 119

id variable affecting outcomes

decision to continue modify terminate plan

Front 120

an outcome where PT has increased knowldege (Ex- verbalizes back or applies knowledge)

Back 120

COGNITIVE

Front 121

a pt achievement of new skills evaluated by asking pt to DEMONSTRATE new skill in action

Back 121

PSYCHOMOTOR

Front 122

a change in patients values, beleifs atttudes evaluated by asking them how they feel about what is happening

Back 122

AFFECTIVE

Front 123

physical change in pt evaluated by vital signs and data

Back 123

PSHYIOLOGIC

Front 124

review goals, collect data , document and revise or modify plan of care are goals of what phase

Back 124

EVALUAITION PHASE

Front 125

documentation of evaluation is

Back 125

goal met
goal not met
goal partially met

Front 126

when do you terminate plan

Back 126

goal was achieved

goals were met partially or not at all, needs tobe reevaluated

Front 127

acceptable, expected levels of performance by rn staff and health team members formulated by boards and authorities internal or extermal.

Back 127

STANDARD

Front 128

programs set up both internally or externally to assure and improve nursing care are called

Back 128

PERFORMANCE IMPROVEMENT /QUALITY ASSURANCE

Front 129

EVALUATION of one staff by another is called

Back 129

peer review

Front 130

allowins nurses to meausre their care

Back 130

quality assurance program

Front 131

activities is what kind of evaluation

Back 131

process

Front 132

change in patient is

Back 132

outcome evaluation

Front 133

review of records can be concurrent or retrospect is what kind of evaluation

Back 133

nursing audit

Front 134

continually imprving nursing process, imrpoves quality, focues on process only

Back 134

quality improvement

Front 135

what ocurs while the patient is recieving acre - HAPPENS NOW! OBSERT, INTEVEW PT ,READ CHART

Back 135

concurrent evaluation!

Front 136

post discharge and care
questionaries
patient interview
chart review

SURVEY AFTER CARE

Back 136

RETROSPECTIVE EVALUATION

EX) SURVERY AFTER CARE

Front 137

what measures the effectiveness of RNcare to help patient meet goals, measures outcome.

Back 137

EVALUATION

Front 138

when the rn determines that the patients anxiety needs to be relieved PRIOR to effective teaching can be implemented, the phase of nursing process used is

Back 138

PLANNING - DONE BEFORE TEACHING

Front 139

Frontal lobe of brain damage affects MEMORY AND PERSONALITY

Back 139

keep instructions simple and brief

orient patient to person place time because of memory problems

Front 140

linkages of nanda nursing diagnoses NOC patient outcomes and NIC interventiosn can be used to

Back 140

provide guide for planningcare

NANDA-NOC-NIC PROVIDE PLANNING CARE GUIDES!

Front 141

What nursing diagnoses needs to gather more data

Back 141

POSSIBLE

Front 142

What nursing diagnoses is at risk

Back 142

POTENTIAL

Front 143

during planning stage - the nurse

Back 143

ID expected outcome
select nursing interventions
communicate the plan of care


PLANNING YOU DO NOT FORMULATE A DIAGNOSE!

Front 144

What activies can be delegated?

Back 144

giving bed bath
taking routine vitals
transfering patient to another floor

Front 145

data that can be observed by one person and verified by another person obvserving the same patient is

Back 145

OBJECTIVE DATA

Front 146

patient only data is

Back 146

SUBJECTIVE