Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
72 Cards in this Set
- Front
- Back
Nursing Process
|
A professional nurse's approach for selecting, organizing and delivering appropriate nursing care to a patient.
|
|
What five steps does the nursing process include?
|
ADPIE:
1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
|
Assessment
|
The deliberate and systematic collection of data to determine a patients current and past health status, functional status, and present and past coping patterns.
|
|
What is the purpose of Assessment?
|
To provide a patient DATABASE about the patient's perceived needs, health problems, and responses to these problems.
|
|
CUE
|
Information that you obtain through the SENSES.
|
|
INFERENCE
|
Your judgment or interpretation of CUES.
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Health perception-health management pattern |
Describes the patient's self-report of health and well-being; how health is managed; knowledge of preventative health practices
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Nutritional-metabolic Pattern |
Describes the patient's daily/weekly pattern of food and fluid intake; actual weight; weight-loss or gain
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Elimination pattern |
Describes pattern of excretory function (bowel, bladder, and skin)
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Activity-exercise pattern |
Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living.
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Sleep-rest pattern |
Describes patterns of sleep, rest, and relaxation
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Cognitive-perceptual pattern |
Describes sensory perceptual patterns; language adequacy, memory, decision making ability.
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Self-perception-self-concept pattern |
Describes the patient's self concept/worth, emotional patterns, body image
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Role-relationship pattern |
Describes the patient's pattern of role engagements and relationships
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Sexuality-reproductive pattern |
Describes the patient's patterns of satisfaction and dissatisfaction w/ sexuality pattern; patient's reproductive pattern; pre-menopausal and post-menopausal problems
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Coping-stress tolerance pattern |
Describes the patient's ability to manage stress; sources of support; effectiveness of the pattern in terms of stress tolerance
|
|
ONE OF 11 FUNCTIONAL HEALTH PATTERNS:
Value-belief pattern |
Describes patterns of values, beliefs (includes spiritual practices), and goals that guide the patient's choices or decisions
|
|
Subjective Data
|
Your patient's perceptions about their health problems
|
|
Objective Data
|
Observations or measurements you make during an assessment
|
|
SOURCES OF DATA:
|
1. Patient
2. Family and Significant Others 3. Health care team 4. Medical records 5. Other records and the literature (Education, Military, and Employment records) |
|
Interview (15-30 min)
An organized conversation with the patient in which you: |
1. Introduce self/title
2. Establish caring relationship 3. Gain insight about pt.'s concerns 4. Determine pt's goals/expectation 5.Obtain clues about which parts of the data collection need in-depth investigation |
|
COMPONENTS FOR NURSING HEALTH HISTORY:
REASONS FOR SEEKING HEALTH CARE |
*GOALS OF CARE
*EXPECTATIONS OF THE SERVICES AND CARE DELIVERED *EXPECTATIONS OF THE HEALTH CARE SYSTEM |
|
COMPONENTS FOR NURSING HEALTH HISTORY:
PRESENT ILLNESS OR HEALTH CONCERN |
ONSET, SYMPTOMS, NATURE OF SYMPTOMS (SUDDEN OR GRADUAL), DURATION, PRECIPITATING FACTORS, RELIEF MEASURES & WEIGHT LOSS OR GAIN
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
HEALTH HISTORY |
PRIOR ILLNESSES THROUGHOUT DEVELOPMENT, INJURIES AND HOSPITALIZATIONS, SURGERIES, BLOOD TRANSFUSIONS, ALLERGIES, IMMUNIZATION, HABITS (SMOKING, DRUGS, CAFFEINE, ETC), MEDICATIONS, WORK HABITS, RELAXATION, SLEEP, EXERCISE, EATING
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
FAMILY HISTORY |
HEALTH HISTORY/STATUS OF THE IMMEDIATE FAMILY
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
ENVIRONMENTAL HISTORY |
HAZARDS, POLLUTANTS, PHYSICAL SAFETY
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
PSYCHOSOCIAL AND CULTURAL HISTORY |
LANGUAGE, CULTURAL GROUP, COMMUNITY RESOURCES, MOOD, ATTENTION SPAN, DEVELOPMENTAL STAGE
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
REVIEW OF SYSTEMS |
HEAD TO TOE REVIEW OF ALL MAJOR BODY SYSTEMS
|
|
COMPONENTS FOR NURSING HEALTH HISTORY:
FUNCTIONAL HEALTH PATTERNS |
METHOD FOR ORGANIZING ASSESSMENT DATA BASED ON FUNCTION
|
|
OPEN-ENDED QUESTIONS
|
PROMPT PATIENTS TO DESCRIBE A SITUATION IN MORE THAN 1 OR 2 WORDS
|
|
BACK CHANNELING
|
INCLUDES ACTIVE LISTENING PROMPTS SUCH AS "ALL RIGHT", "GO ON" OR "UH-HUH" TO INDICATE YOU HAVE HEARD WHAT THE PATIENT SAYS OR ARE ATTENTIVE
|
|
CLOSED-ENDED QUESTIONS
|
LIMIT THE PATIENT'S ANSWERS TO 1 OR 2 WORDS--USED TO IDENTIFY SPECIFIC PROBLEMS AREAS
|
|
PHYSICAL EXAMINATION
|
AN INVESTIGATION OF THE BODY TO DETERMINE ITS STATE OF HEALTH
|
|
DATA ANALYSIS
|
INVOLVES RECOGNIZING VALUES OR TRENDS, COMPARING THEM WITH STANDARDS, & THEN COMING TO A REASONED CONCLUSION ABOUT THE PATIENT'S RESPONSE TO A HEALTH PROBLEM
|
|
DATA CLUSTER
|
A SET OF SIGNS OR SYMPTOMS THAT ARE GROUPED TOGETHER IN A LOGICAL ORDER
|
|
NURSING DIAGNOSIS
|
A CLINICAL JUDGMENT ABOUT INDIVIDUAL, FAMILY, OR COMMUNITY RESPONSES TO ACTUAL OR POTENTIAL HEALTH PROBLEMS OR LIFE PROCESSES/ IT IS A STATEMENT THAT DESCRIBES THE PT'S ACTUAL OR POTENTIAL RESPONSE TO A HEALTH PROBLEM THAT THE NURSE IS LICENSED AND COMPETENT TO TREAT
|
|
MEDICAL DIAGNOSIS
|
THE ID OF A DISEASED CONDITION BASED ON A SPECIFIC EVALUATION OF PHYSICAL SIGNS, SYMPTOMS, HISTORY, DIAGNOSTIC TESTS, AND PROCEDURES
|
|
COLLABORATIVE PROBLEM
|
A PHYSIOLOGICAL COMPLICATION THAT NURSES MONITOR TO DETECT THE ONSET OR CHANGES IN A PT'S STATUS
|
|
NANDA INTERNATIONAL
|
PROVIDES A PRECISE DEFINITION THAT GIVES ALL MEMBERS OF THE HEALTH CAR TEAM A COMMON LANGUAGE FOR UNDERSTANDING THE PT'S NEEDS
DISTINGUISHES THE NURSES ROLE FROM THAT OF THE PHYSICIAN OR H.C. PROVIDER HELPS NURSES FOCUS ON THE SCOPE OF NURSING PRACTICE |
|
DIAGNOSTIC PROCESS
|
FLOWS FROM THE ASSESSMENT PROCESS AND INCLUDES DECISION-MAKING STEPS
|
|
DEFINING CHARACTERISTICS
|
THE CLINICAL CRITERIA OR ASSESSMENT FINDINGS THAT SUPPORT AN ACTUAL NURSING DIAGNOSIS
|
|
CLINICAL CRITERIA
|
OBJECTIVE OR SUBJECTIVE SIGNS AND SYMPTOMS, CLUSTERS OF SIGN AND SYMPTOMS OR RISK FACTORS
|
|
PROBLEM IDENTIFICATION PHASE
|
THE GENERAL HEALTH CARE PROBLEM AND THE FORMULATION OF THE NURSING DIAGNOSIS AS THE SPECIFIC HEALTH PROBLEM
|
|
ACTUAL NURSING DIAGNOSIS
|
DESCRIBES HUMAN RESPONSES TO HEALTH CONDITIONS OR LIFE PROCESSES THAT EXIST IN AN INDIVIDUAL OR COMMUNITY
|
|
RISK NURSING DIAGNOSIS
|
DESCRIBES HUMAN RESPONSES TO HEALTH CONDITIONS OR LIFE PROCESSES THAT HAVE A CHANCE OF DEVELOPING IN A VULNERABLE INDIVIDUAL, FAMILY, OR COMMUNITY
|
|
WELLNESS NURSING DIAGNOSIS
|
DESCRIBES HUMAN RESPONSES TO LEVELS OF WELLNESS IN AN INDIVIDUAL, GROUP, OR COMMUNITY THAT HAVE A READINESS FOR ENHANCEMENT OR IMPROVEMENT.
|
|
DIAGNOSTIC LABEL
|
THE NAME OF THE NURSING DIAGNOSIS AS APPROVED BY NANDA INTERNATIONAL. IT DESCRIBES THE ESSENCE OF A PT'S RESPONSE TO HEALTH CONDITIONS IN AS FEW WORDS AS POSSIBLE.
|
|
RELATED FACTOR
|
A CONDITION OR ETIOLOGY IDENTIFIED FROM THE PT'S ASSESSMENT DATA
|
|
ETIOLOGY
|
CAUSE OF THE NURSING DIAGNOSIS
|
|
MIND MAPPING
|
A WAY TO GRAPHICALLY REPRESENT THE CONNECTIONS BETWEEN CONCEPTS (NURSING DIAGNOSIS) THAT ARE RELATED TO A CENTRAL SUBJECT (A PT'S HEALTH PROBLEMS)
|
|
PLANNING
|
THE 3RD STEP IN THE NURSING PROCESS
|
|
GOAL
|
A SPECIFIC AND MEASURABLE BEHAVIOR OR RESPONSE THAT REFLECTS THE PT'S HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION
|
|
EXPECTED OUTCOME
|
A SPECIFIC MEASURABLE CHANGE IN A PT'S STATUS THAT YOU EXPECT TO OCCUR IN RESPONSE TO NURSING CARE
|
|
SCIENTIFIC RATIONALE
|
REASON
|
|
NURSE-INITIATED INTERVENTIONS
|
THE INDEPENDENT RESPONSES OF THE NURSE TO A PT'S NURSING DIAGNOSIS AND HEALTH CARE NEEDS
|
|
PHYSICIAN-INITIATED INTERVENTIONS
|
BASED ON THE PHYSICIAN'S RESPONSE TO TREAT OR MANAGE A MEDICAL DIAGNOSIS
|
|
COLLABORATIVE INTERVENTIONS
|
THERAPIES THAT REQUIRE THE COMBINED KNOWLEDGE, SKILL AND EXPERTISE OF MULTIPLE HEALTH CARE PROFESSIONALS
|
|
CONCEPT MAPS
|
A VISUAL REPRESENTATION OF PT. PROBLEMS AND INTERVENTIONS THAT SHOWS THEIR RELATIONSHIPS TO ONE ANOTHER
|
|
CRITICAL PATHWAYS
|
ALLOW STAFF FROM ALL DISCIPLINES, SUCH AS MEDICINE, NURSING, AND PHARMACY, TO DEVELOP INTEGRATED CARE PLANS FOR A PROJECTED LENGTH OF STAY OR # OF VISITS FOR PT'S W/ A SPECIFIC CASE TYPE
|
|
IMPLEMENTATION
|
THE FOURTH STEP OF THE NURSING PROCESS THAT INVOLVES THE PROVISION OF CARE TO PT'S
|
|
NURSING INTERVENTION
|
ANY TREATMENT BASED UPON CLINICAL JUDGMENT & KNOWLEDGE THAT A NURSE PERFORMS TO ENHANCE PT OUTCOMES
|
|
DIRECT CARE INTERVENTIONS
|
TREATMENTS PERFORMED THROUGH INTERACTION WITH THE PT.
|
|
INDIRECT CARE INTERVENTIONS
|
TREATMENTS PERFORMED AWAY FROM THE PT BUT ON BEHALF OF THE PT OR GROUP OF PTS. (E.G. SAFETY & INFECTION CONTROL, DOCUMENTATION, INTERDISCIPLINARY COLLABORATION
|
|
PROTOCOL
|
A WRITTEN PLAN SPECIFYING THE PROCEDURES TO BE FOLLOWED DURING CARE OF PT'S W/ SELECT CLINICAL CONDITION OR SITUATION (EXAMPLE: ADMINISTRATION OF CHEMOTHERAPY)
|
|
STANDING ORDER
|
A PREPRINTED DOCUMENT CONTAINING ORDERS FOR THE CONDUCT OF ROUTINE THERAPIES, MONITORING GUIDELINES, &/OR DIAGNOSTIC PROCEDURES FOR SPECIFIC PT'S W/ IDENTIFIED CLINICAL PROBLEMS
|
|
IMPLEMENTATION SKILLS
|
1. COGNITIVE SKILLS
2. INTERPERSONAL SKILLS 3. PSYCHOMOTOR SKILLS |
|
DIRECT CARE INCLUDES:
|
1. ACTIVITIES OF DAILY LIVING
2. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (SHOPPING, MEALS, CHECKS, MEDICATION) 3. PHYSICAL CARE 4. COUNSELING 5. TEACHING 6. CONTROLLING FOR ADVERSE REACTIONS 7. PREVENTATIVE MEASURES |
|
ADVERSE REACTION
|
A HARMFUL OR UNINTENDED EFFECT OF A MEDICATION, DIAGNOSTIC TEST, OR THERAPEUTIC INTERVENTION
|
|
PREVENTATIVE NURSING ACTIONS
|
PROMOTE HEALTH AND PREVENT ILLNESS TO AVOID THE NEED FOR ACUTE OR REHABILITATIVE HEALTH CARE
|
|
INDIRECT CARE INCLUDES
|
DELEGATING, SUPERVISING, AND EVALUATING THE WORK OF OTHER STAFF MEMBERS
|
|
EVALUATION
|
CRUCIAL TO DETERMINE WHETHER AFTER APPLICATION OF THE NURSING PROCESS, A PT'S CONDITION OR WELL-BEING IMPROVES
|
|
STANDARD OF CARE
|
THE MINIMUM LEVEL OF CARE ACCEPTED TO INSURE HIGH QUALITY OF CARE TO PTS
|