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110 Cards in this Set

  • Front
  • Back
the ability and willingness to assume responsibility for one’s actions and to accept the consequences for one’s behavior
to separate into parts or principles in order to determine the nature of the whole; to examine methodically
abstract ideas or mental images of Phenomena or reality
a process in which two or more people deliberate with one another to seek advice or clarification
a standard or attribute for judging a condition or establishing a diagnosis
Subjective or objective data that can be directly observed; i.e., what client says or what is seen, heard, felt, smelled or measured.
Data base
all information about a client, includes nursing health history and physical assessment, physician’s history, physical examination and laboratory and diagnostic test results
Defining characteristics
client signs and symptoms that must be present to validate a nursing diagnosis
Health problem
any condition or situation in which a client requires help tp promote, maintain or regain a state of health or to achieve a peaceful death
Health status
the health of a person at a given time
Interpersonal skills
all verbal and non-verbal activities people use when communicating directly with one another
a planned communication; a conversation with a purpose. E.G. to get information; ID problems of mutual concern etc...
the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing-care especially care that changes frequently and must be kept up to date
North American Nursing Diagnosis Association... purpose of organizaton is to define, refine and promote taxonomy of nursing diagnostic terminology of general use for nurses.
Nursing audit
a procedure to evaluate the quality of nursing care provided for a patient
Objective data
information (data) that is detectable by an observer or can be tested against an acceptable standard. Can be seen, heard, felt or smelled
Peer review
the evaluation of the quality of the work effort of an individual by his or her peers
Priority setting
the process of establishing a preferential order for nursing strategies, diagnoses etc..
a predetermined and preprinted plan specifying the procedure to be followed in a particular situation
Quality assurance
activities and programs designed to achieve desired levels of care
a generally accepted rule, model, pattern or measure
AKA: Norm
Standing order
- a written document about policies, rules, regulations or orders regarding client care; gives nurses the authority to carry out specific actions under certain circumstances
Subjective data
data that are apparent only to the person affected; can be described or verified only by that person
Unit standards of care
Detailed guidelines describing the minimal nursing care that can reasonably be expected to ensure high quality care in a defined situation.
2.) Define critical thinking (p245)
“the intellectually disciplined process of actively and skillfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from or generated by observation, experience, reflection, reasoning or communication, as a guide to belief and action”
3.) Discuss how nurses use critical thinking skills in practice (p 245)
* use knowledge from other subjects and fields.
* deal with change in stressful environments
* make important decisions
3.) An example of a nurse using critical thinking with Knowledge of other subjects and fields is...
life experience, other jobs, travel experience etc...can all be consolidated in nursing practice.
3.) An example of a nurse using critical thinking in a stressful environment is...
unexpected situations arise and critical thinking enables the nurse to recognize important cues, respond quickly and adapt interventions to meet specific client needs
3.) An example of a nurse using critical thinking when making important decision...
Discernment of large volume of data to determine what to prioritize.
4.) Identify attitudes that foster critical thinking(p 247-249)
Independence of thought; Fair-mindedness; Insight into egocentricity and sociocentricity; Intellectual Humility and suspension judgement; Intellectual courage; Integrity; Perseverance; Confidence in reason; Interest in exploring both thought and feelings; Curiosity.
5. Discuss how critical thinking attitudes and skills are developed
Kozier p. 252-253
By practicing Critical thinking skills in positive environments with good critical thinkers: Self-Assessment; Tolerating Dissonance and Ambiguity; Seeking Situations Where Good Thinking Is Practiced; Creating Environments That Support Critical Thinking.
6. Identify the five steps in the nursing process –
Kozier p. 257-259
6. Characteristics of the Assessment part of the Nursing Process are...
• Collect data
• Organize data
• Validate data
• Document data
6. Characteristics of the Diagnosing part of the Nursing Process are...
• Analyze data
• Identify health problems, risks, and strengths
• Formulate diagnostic statements
6. Characteristics of the Planning part of the Nursing Process are...
• Prioritize problems/diagnoses
• Formulate goals/desired outcomes
• Select nursing interventions
• Write nursing orders
6. Characteristics of the Implementing part of the Nursing Process are...
• Reassess the client
• Determine the nurse’s need for assistance
• Implement the nursing interventions
• Supervise delegated care
• Document nursing activities
6. Characteristics of the Evaluating part of the Nursing Process are...
• Collect data related to outcomes
• Compare data with outcomes
• Relate nursing actions to client goals/outcomes
• Draw conclusions about problem status
• Continue, modify, or terminate the client’s care plan
7. Describe and discuss characteristics of the nursing process –
Kozier p. 257-261
The nursing process has unique characteristics that enable responsiveness to the changing health status of the client. These characteristics include its cyclic and dynamic nature, client centeredness, focus on problem solving and decision making, interpersonal and collaborative style, universal applicability, and use of critical thinking.
7. Describe and discuss the cyclic and dynamic nature of the nursing process –
Kozier p. 257-261
• Data from each phase provides input into the next phase. Findings from evaluating feedback into assessing. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle) that are continuously changing (dynamic) rather than staying the same (static).
7. Describe and discuss the integration of problem solving and systems theory in the nursing process –
Kozier p. 257-261
Using both processes, nursing begins with data gathering and analysis and bases action on a problem statement; further nursing includes an evaluative component.
7. Describe and discuss the client centered nature of the nursing process –
Kozier p. 257-261
The nurse organizes the plan of care according to client problems rather than nursing goals.
7. Describe and discuss the importance of decision making in the nursing process –
Kozier p. 257-261
It is involved in every phase of the nursing process. Nurses can be highly creative in determining when and how to use data to make decisions.
7. Describe and discuss interpersonal and collaborative aspects of the nursing process –
Kozier p. 257-261
Nursing requires the nurse to communicate directly and consistently with clients and families to meet their needs. It also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality client care.
7. Describe and discuss the universality of the nursing process –
Kozier p. 257-261
universally acceptable characteristic of the nursing process means that it is used as a framework for nursing care in all types of health care settings, with clients of all age groups.
7. Describe and discuss the Critical thinking and the nursing process –
Kozier p. 257-261
see cards on Critical thinking.
8. What are the activities involved in the assessment phase of the nursing process.
1 Nursing health history
2 Primary and secondary sources of data collection
3 Data collection
4Validating and documenting data
8. What does the Nursing health history of the assessment include?
• Biographic data
• Chief complaint or reason for visit
• History of present illness and other medical history
• Family history of illness
• Lifestyle, Social, Psychologic data
• Patterns of Health Care
8. What are Primary and secondary sources of data collection (relative to assessment part of nursing process)?
The primary source is the client.
Secondary sources can be support people, the client’s records, other health care professionals, and/or literature.
8. What are the Data Collection Methods used for the assessment part of nursing process?
The primary methods are observing, interviewing, and examining. Observation: whenever the nurse is in contact with the client or support persons.
Interviewing: taking the nursing health history.
Examining: major method used in physical assessment.
8. How are Validating and Documenting data relevant to the assessment part of nursing process?
Information must be complete, factual, and accurate. Nursing diagnoses and interventions are based on this information
8. What tasks does the validation of data help a nurse complete?
• Ensure that assessment information is complete.
• Ensure that objective and related subjective data agree.
• Obtain additional information that may have been overlooked.
• Differentiate between cues and inferences.
• Avoid jumping to conclusions and focusing in the wrong direction to identify problems.
8. Describe the documentation part of the assessment process?
*completes the assessment phase.
*should include all data collected about the client’s health status
*recorded in a factual manner and not interpreted by the nurse
*the nurse records subjective data in the client’s own words
9. Identify the five types of nursing diagnosis –
Kozier p. 279
*wellness, risk, actual, possible, syndrome. (WRAPS)
9. What is a wellness nursing diagnosis?
describes human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. E.g. "readiness for enhanced family coping".
9. What is a risk nursing diagnosis?
a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. E.g. client with diabetes is at higher risk of infection.
9. What is an actual nursing diagnosis?
a client problem that is present at the time of the nursing assessment. An actual nursing diagnosis is based on the presence of associated signs and symptoms. E.g ineffective breathing pattern.
9. What is a possible nursing diagnosis?
evidence about a health problem is incomplete or unclear. A possible diagnosis requires more data either to support or to refute it. E.g. "Possible social isolation".
9. What is a syndrome nursing diagnosis?
a diagnosis that is associated with a cluster of other diagnoses.
9. How many syndrome nursing diagnoses are listed with NANDA?
Six. E.g., Risk for Disuse Syndrome...
(cluster's of diagnoses are associated with this syndrome)
10. List the components of a NANDA nursing diagnosis –
Kozier p. 279-281
It has three:
the problem and its definition
the etiology
the defining characteristics.
10. Describe the problem statement, or diagnostic label of the NANDA nursing diagnosis:
describes the client’s health problem or response for which nursing therapy is given. If describes the client’s health status clearly and concisely in a few words.
10. Describe the etiology component of the NANDA nursing diagnosis:
identifies one or more probable causes of the health problem, gives direction to the required nursing therapy, and enables the nurse to individualize the client’s care.
10. Describe the Defining Characteristics component of the NANDA nursing diagnosis:
the cluster of signs and symptoms that indicate the presence of a particular diagnostic label. For actual diagnoses, the defining characteristics are the client’s signs and symptoms. For risk diagnoses, no subjective and objective signs are present.
11. Differentiate between a nursing diagnosis and a medical diagnosis –
Kozier p. 280-281
nursing diagnosis: A statement of a nursing judgmen; refers to a condition that nurses are licensed to treat.
medical diagnosis: Made by a physician and refers to a condition that only a physician is licensed to treat.
11. To what do Medical Diagnoses refer?
Medical diagnoses refer to disease processes – specific pathophysiologic responses that are fairly uniform from one client to another. Medical diagnosis remains the same for as longs ad the disease process is present
11. To what do Nursing Diagnoses refer?
A client’s physical, sociocultural, psychologic, and spiritual responses to an illness or a health problem
Nursing diagnoses change as the client’s responses change.
11. Do nurses have responsibilities relative to medical diagnoses?
Yes; while nursing diagnoses relate to the nurses independent functions, with regard to medical diagnoses, nurses are obligated to carry out physician prescribed therapies and treatments
12. What is a collaborative problem –
Kozier p. 281
A collaborative problem is a type of potential problem that nurses manage using both independent and physician-prescribed interventions. Collaborative problems tend to be present when a particular disease or treatment is present; that is each disease or treatment has specific complications that are always associated with it.
12. How is a nursing diagnosis different than a collaborative problem?
Nursing diagnoses involve human responses; vary greatly from one person to the next. Therefore the same set of nursing diagnoses cannot be expected to occur with a particular disease or condition; moreover, a single nursing diagnosis may occur as a response to any number of diseases.
13. What are the three parts of the nursing diagnostic process ?
Kozier p. 281-287
1 Analyzing Data
2 Identifying Health Problems, Risks, and Strengths
3 Formulating Diagnostic Statements
13. What are the two critical thinking skills used in the diagnostic process?
Analysis: the separation into components (i.e. the breaking down of the whole into its parts)
Synthesis: the putting together of parts into the whole
13. What are the 3 steps in analyzing data in the diagnosis part of the nursing process?
• Comparing data against standards (identify significant cues)
• Cluster cues (generate tentative hypotheses)
• Identify gaps and inconsistencies
13. Describe the 2nd part of the diagnosis part of the nursing process: Identifying health problems, risks, strengths:
After grouping and clustering the data, the nurse and client together identify problems that support tentative actual, risk, and possible diagnoses.
Nurse and client also establish the client’s strengths, resources, and abilities to cope. Strengths can be an aid to mobilizing health and regenerative processes.
13. How are Diagnostic Statements written?
Most nursing diagnoses are written as two-part or three-part statements, but there are variations.
14. How is a Basic Two-part Statement (diagnosis) written?
include the following:
• Problem (P) – statement of the client’s response (NANDA label)
• Etiology (E) – factors contributing to or probable causes of the responses.
The two parts are joined by the words related to rather than due to.
14. How is a Basic three-part Statement (diagnosis) written?
called the PES format. includes the following:
• Problem (P) – statement of the client’s response (NANDA label)
• Etiology (E) – factors contributing to or probable causes of the response.
• Signs and Symptoms (S) – defining characteristics manifested by the client.
Actual nursing diagnoses can be documented by using the three-part statement because the signs and symptoms have been identified.
14. What is a One-Part Statement?
Consist's of a NANDA label only.
e.g., some diagnostic statements, such as wellness diagnoses and syndrome nursing diagnoses
15. Discuss NANDA specifications for one-part diagnostic statements –
Kozier p. 287
NANDA has specified that any new wellness diagnoses will be developed as one-part statements beginning with the words Readiness for Enhanced followed by the desired higher level wellness.
16. Discuss collaborative problems –
Kozier p. 287
Carpenito suggests that all collaborative (multidisciplinary) problems begin with the diagnostic label Potential Complication (PC).
Nurses should include in the diagnostic statement both the possible complication they are monitoring and the disease or treatment that is present to produce it.
16. Discuss collaborative problems – (elaborate more on what a nurse should do when monitoring for a group of complications associated with a disease or pathology:
Kozier p. 287
Nurse states the disease and follows it with a list of the complications.
In some situations an etiology might be helpful in suggesting interventions. Nurses should write the etiology when it clarifies the problem statement, it can be concisely stated, and it helps to suggest nursing actions.
17. Identify ways to avoid errors in diagnostic reasoning –
Kozier p. 288-289
• Verify the diagnosis
• Build a good knowledge base and acquire clinical experience
• Have a working knowledge of what is normal
• Consult resources
• Base diagnoses on patterns: on behavior over time, rather than on an isolated incident.
• Improve critical thinking skills (helps to avoid errors in thinking, such as overgeneralizing, stereotyping)
18. Identify activities involved in the planning stage of the nursing process –
Kozier p. 293-294
In general, planning begins with the first client contact and continues until the nurse-client relationship ends, usually when the client is discharged from the health care agency.
18. Identify 3 specific phases involved in the planning stage of the nursing process –
Kozier p. 293-294
1 Initial Planning: usually by nurse who performs the admission assessment
2 Ongoing Planning: done by all nurses who work with the client.
3 Discharge Planning: the process of anticipating and planning for needs after discharge (a crucial part of comprehensive health care; should be addressed in each client’s care plan.)
18. Elaborate on "ongoing planning":

Kozier p. 293-294
Obtain new information/evaluate the client’s responses to care, then further individualize the initial care plan :
• To determine whether health status has changed.
• To set priorities for the client’s care during the shift.
• To decide which problems to focus on during the shift.
• To coordinate the nurse’s activities so that more than one problem can be addressed at each client contact.
19. Discuss the reasons for comprehensive discharge planning and the activities involved:
Kozier p. 294
Often, clients are discharged still needing care. Such care is increasingly delivered in the home. Effective discharge planning begins at first client contact and involves comprehensive and ongoing assessment to obtain information about the client’s ongoing needs.
20. What are 4 different types of care plans?

Kozier p. 294-298
• Standardized care plans: formal plan that specifies the care for groups of clients with common needs, e.g., myocardial infarction will have the same specific care plan.
• Individualized care plans: tailored to meet the unique needs of a specific client; not addressed by the standardized plan.
• Student care plans: a learning activity as well as a plan of care: may be more lengthy and detailed than care plans used by working nurses.
• Computerized care plans
20. Describe Computerized Care plans:
The computer can generate both standardized and individualized care plans. For an individualized plan the nurse chooses the appropriate diagnoses from a menu; computer then lists possible goals and nursing interventions for those diagnoses. Nurse choose appropriate one and types any additional goals/interventions.
21. Discuss the guidelines for writing nursing care plans: (1-3 of 10)

Kozier p. 298
• Date and sign the plan. The date the plan is written is essential for evaluation, review, and future planning.
• Use category headings such as “Nursing Diagnoses,” or “Goals/Desired Outcome.”
• Use standardized medical or English symbols and keywords rather than complex sentences
21. Discuss the guidelines for writing nursing care plans: (4-5 of 10)

Kozier p. 298
• Be specific.
• Refer to procedure books or other sources of information rather than including all steps on a written plan. Write “See unit procedure book for tracheostomy care.”
21. Discuss the guidelines for writing nursing care plans: (6-7 of 10)

Kozier p. 298
• Tailor the plan to unique client characteristics by ensuring that client choices e.g., times of care and the methods used, are included (reinforces the client’s individuality/sense of control).
• Ensure that the nursing plan incorporates preventive and health maintenance aspects as well as restorative ones.
21. Discuss the guidelines for writing nursing care plans: (8-10 of 10)

Kozier p. 298
• Ensure that the plan contains interventions for ongoing assessment of the client.
• Include collaborative and coordination activities in the plan.
• Include plans for the client’s discharge and home care needs.
22. Discuss priority setting (x3)
Kozier p. 299
Process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
High priority: life threatening problems, loss of respiration or cardiac functions.
Medium priority: health threatening problems, acute illnesses, decreased coping ability.
Low priority: arises from normal developmental needs or that requires only minimal nursing support.
22. Factors to consider when assigning priorities –
Kozier p. 299
• Client’s health values and beliefs.
• Client’s priorities.
• Resources available to the nurse and client.
• Urgency of the health problem.
• Medical treatment plan.
23. Identify the purpose of desired outcomes/goals –
Kozier p. 301
• Provide direction for planning nursing interventions.
• Serve as criteria for evaluating client progress.
• Enable the client and nurse to determine when the problem has been resolved.
• Help motivate the client and nurse by providing a sense of achievement.
24. Differentiate between a long-term and a short-term goal –
Kozier p. 301-302
Short-term goals: useful for clients who require health care for a short time; and for those who are frustrated by long-term goals that seem difficult to attain/ need the satisfaction of achieving a short-term goal.
Long-term goals are often used for clients who live at home and have chronic health problems and for clients in nursing homes, extended care facilities, and rehabilitation centers.
25. Discuss the relationship of desired outcomes/goals to nursing diagnoses –
Kozier p. 302
For every diagnosis, nurse must write at least one desired outcome that, when achieved, directly demonstrates resolution of the problem cause.
25. When developing goals/desired outcomes, ask the following questions:
• What is the problem cause?
• What is the opposite, healthy response?
• How will the client look or behave if the healthy response is achieved?
• What must the client do and how well must the client do it to demonstrate problem resolution or to demonstrate the capability of resolving the problem?
26. Identify the components of desired outcome/goal statements :

Kozier p. 302-303
• Subject – client
• Verb – action client is to perform
• Conditions or modifiers – explain how behavior is to be performed
• Criterion of desired performance – the standard by which a performance is evaluated or the level at which the client will perform the specific behaviour.
26. Discuss the guidelines for writing outcome/goal statements –
Kozier p. 302-303
• Write goals/outcomes in terms of client responses: "Client will..."
• Be sure that desired outcomes are realistic for client’s capabilities, limitations, and designated time span
• Make sure that each goal is derived from only one nursing diagnosis.
• Use observable, measurable terms for outcomes.
• Make sure the client considers the goals/desired outcomes important and values them.
27. Identify the three types of nursing interventions –
Kozier p. 305-306
1. Independent interventions / AKA 'nurse
2. Dependent interventions / AKA physician initiated treatments'.
3. Collaborative interventions
27. Describe Independent Interventions:
1. Independent interventions – Those activities that nurses are licensed to initiate on the basis of their knowledge and skills. AKA 'nurse-initiated treatments'.
27. Describe Dependent Interventions:
Activities that are carried out under the physician’s order or supervision, or according to specified routines. They can also be referred to as physician-initiated treatments.
27. Describe Collaborative Interventions:
Activities that the nurse carries out in collaboration with other health team members, such as physical therapists, social workers...
28. Describe nursing orders:
Kozier p. 306-307
After choosing the appropriate nursing interventions, the nurse writes them on the care plan as nursing orders. Nursing orders are instructions for the specific individualized activities the nurse performs to help the client meet established health care goals.
28. Identify and discuss the information to be included in writing nursing orders –
Kozier p. 306-307
• Date: dated when they are written/ reviewed regularly at intervals that depend on the individual’s needs.
• Action Verb – the action verb starts the order and must be precise.
• Content Area – the content is the what and the where of the order.
• Time Element – the time element answers when, how long, or how often the nursing action is to occur.
• Signature (of prescriber/ legal)
29. Identify the activities that are included in the implementation phase of the nursing process (x5)
Kozier p. 317-318
• Reassessing the client
• Determining the nurse’s need for assistance
• Implementing the nursing intervention
• Supervising the delegated care
• Documenting nursing activities
29. Guidelines for Implementing nursing interventions:
Kozier p. 317-8
o Base nursing interventions on scientific knowledge, nursing research, and professional standards of care
o Clearly understand the orders to be implemented / question any that are not understood.
o Adapt activities to the individual client. o Implement safe care.
o Provide teaching, support, and comfort. o Be holistic.
o Respect the dignity of the client and enhance the client’s self-esteem.
o Encourage clients to participate actively in implementing the nursing interventions.
29. What is the completion of the implementaton phase?
• Documenting nursing activities by recording the interventions and client responses in the nursing program notes.
Nursing activities are communicated verbally as well as in writing.
30. Discuss the evaluation of the quality of nursing care: (x4)
Kozier p. 322-323
Quality assurance program: Requires evaluation of three components of care: structure, process, and outcome evaluations.
30. Describe the 3 components of evaluation:
Kozier p. 322-323
Structure evaluation: “What effect does the setting have on the quality of care?”
Process evaluation: “Is the care relevant to the client’s needs? Is the care appropriate, complete, and timely?” Also focuses on the manner in which the nurse uses the nursing process.
Outcome evaluation – Focuses on demonstrable changes in the client’s health status as a result of nursing care. Written in terms of client responses or health status, same as evaluation.