Basic Nursing 6Th Edition Chapter 7

Front 1

Nursing Process

Back 1

A professional nurse's approach for selecting, organizing and delivering appropriate nursing care to a patient.

Front 2

What five steps does the nursing process include?

Back 2

1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation

Front 3

Assessment

Back 3

The deliberate and systematic collection of data to determine a patients current and past health status, functional status, and present and past coping patterns.

Front 4

What is the purpose of Assessment?

Back 4

To provide a patient DATABASE about the patient's perceived needs, health problems, and responses to these problems.

Front 5

CUE

Back 5

Information that you obtain through the SENSES.

Front 6

INFERENCE

Back 6

Your judgment or interpretation of CUES.

Front 7

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Health perception-health management pattern

Back 7

Describes the patient's self-report of health and well-being; how health is managed; knowledge of preventative health practices

Front 8

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Nutritional-metabolic Pattern

Back 8

Describes the patient's daily/weekly pattern of food and fluid intake; actual weight; weight-loss or gain

Front 9

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Elimination pattern

Back 9

Describes pattern of excretory function (bowel, bladder, and skin)

Front 10

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Activity-exercise pattern

Back 10

Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living.

Front 11

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Sleep-rest pattern

Back 11

Describes patterns of sleep, rest, and relaxation

Front 12

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Cognitive-perceptual pattern

Back 12

Describes sensory perceptual patterns; language adequacy, memory, decision making ability.

Front 13

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Self-perception-self-concept pattern

Back 13

Describes the patient's self concept/worth, emotional patterns, body image

Front 14

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Role-relationship pattern

Back 14

Describes the patient's pattern of role engagements and relationships

Front 15

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Sexuality-reproductive pattern

Back 15

Describes the patient's patterns of satisfaction and dissatisfaction w/ sexuality pattern; patient's reproductive pattern; pre-menopausal and post-menopausal problems

Front 16

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Coping-stress tolerance pattern

Back 16

Describes the patient's ability to manage stress; sources of support; effectiveness of the pattern in terms of stress tolerance

Front 17

ONE OF 11 FUNCTIONAL HEALTH PATTERNS:

Value-belief pattern

Back 17

Describes patterns of values, beliefs (includes spiritual practices), and goals that guide the patient's choices or decisions

Front 18

Subjective Data

Back 18

Your patient's perceptions about their health problems

Front 19

Objective Data

Back 19

Observations or measurements you make during an assessment

Front 20

SOURCES OF DATA:

Back 20

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)

Front 21

Interview (15-30 min)

Back 21

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

Front 22

COMPONENTS FOR NURSING HEALTH HISTORY:

REASONS FOR SEEKING HEALTH CARE

Back 22

*GOALS OF CARE
*EXPECTATIONS OF THE SERVICES
AND CARE DELIVERED
*EXPECTATIONS OF THE HEALTH CARE SYSTEM

Front 23

COMPONENTS FOR NURSING HEALTH HISTORY:

PRESENT ILLNESS OR HEALTH CONCERN

Back 23

ONSET, SYMPTOMS, NATURE OF SYMPTOMS (SUDDEN OR GRADUAL), DURATION, PRECIPITATING FACTORS, RELIEF MEASURES & WEIGHT LOSS OR GAIN

Front 24

COMPONENTS FOR NURSING HEALTH HISTORY:

HEALTH HISTORY

Back 24

PRIOR ILLNESSES THROUGHOUT DEVELOPMENT, INJURIES AND HOSPITALIZATIONS, SURGERIES, BLOOD TRANSFUSIONS, ALLERGIES, IMMUNIZATION, HABITS (SMOKING, DRUGS, CAFFEINE, ETC), MEDICATIONS, WORK HABITS, RELAXATION, SLEEP, EXERCISE, EATING

Front 25

COMPONENTS FOR NURSING HEALTH HISTORY:

FAMILY HISTORY

Back 25

HEALTH HISTORY/STATUS OF THE IMMEDIATE FAMILY

Front 26

COMPONENTS FOR NURSING HEALTH HISTORY:

ENVIRONMENTAL HISTORY

Back 26

HAZARDS, POLLUTANTS, PHYSICAL SAFETY

Front 27

COMPONENTS FOR NURSING HEALTH HISTORY:

PSYCHOSOCIAL AND CULTURAL HISTORY

Back 27

LANGUAGE, CULTURAL GROUP, COMMUNITY RESOURCES, MOOD, ATTENTION SPAN, DEVELOPMENTAL STAGE

Front 28

COMPONENTS FOR NURSING HEALTH HISTORY:

REVIEW OF SYSTEMS

Back 28

HEAD TO TOE REVIEW OF ALL MAJOR BODY SYSTEMS

Front 29

COMPONENTS FOR NURSING HEALTH HISTORY:

FUNCTIONAL HEALTH PATTERNS

Back 29

METHOD FOR ORGANIZING ASSESSMENT DATA BASED ON FUNCTION

Front 30

OPEN-ENDED QUESTIONS

Back 30

PROMPT PATIENTS TO DESCRIBE A SITUATION IN MORE THAN 1 OR 2 WORDS

Front 31

BACK CHANNELING

Back 31

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

Front 32

CLOSED-ENDED QUESTIONS

Back 32

LIMIT THE PATIENT'S ANSWERS TO 1 OR 2 WORDS--USED TO IDENTIFY SPECIFIC PROBLEMS AREAS

Front 33

PHYSICAL EXAMINATION

Back 33

AN INVESTIGATION OF THE BODY TO DETERMINE ITS STATE OF HEALTH

Front 34

DATA ANALYSIS

Back 34

INVOLVES RECOGNIZING VALUES OR TRENDS, COMPARING THEM WITH STANDARDS, & THEN COMING TO A REASONED CONCLUSION ABOUT THE PATIENT'S RESPONSE TO A HEALTH PROBLEM

Front 35

DATA CLUSTER

Back 35

A SET OF SIGNS OR SYMPTOMS THAT ARE GROUPED TOGETHER IN A LOGICAL ORDER

Front 36

NURSING DIAGNOSIS

Back 36

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

Front 37

MEDICAL DIAGNOSIS

Back 37

THE ID OF A DISEASED CONDITION BASED ON A SPECIFIC EVALUATION OF PHYSICAL SIGNS, SYMPTOMS, HISTORY, DIAGNOSTIC TESTS, AND PROCEDURES

Front 38

COLLABORATIVE PROBLEM

Back 38

A PHYSIOLOGICAL COMPLICATION THAT NURSES MONITOR TO DETECT THE ONSET OR CHANGES IN A PT'S STATUS

Front 39

NANDA INTERNATIONAL

Back 39

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

Front 40

DIAGNOSTIC PROCESS

Back 40

FLOWS FROM THE ASSESSMENT PROCESS AND INCLUDES DECISION-MAKING STEPS

Front 41

DEFINING CHARACTERISTICS

Back 41

THE CLINICAL CRITERIA OR ASSESSMENT FINDINGS THAT SUPPORT AN ACTUAL NURSING DIAGNOSIS

Front 42

CLINICAL CRITERIA

Back 42

OBJECTIVE OR SUBJECTIVE SIGNS AND SYMPTOMS, CLUSTERS OF SIGN AND SYMPTOMS OR RISK FACTORS

Front 43

PROBLEM IDENTIFICATION PHASE

Back 43

THE GENERAL HEALTH CARE PROBLEM AND THE FORMULATION OF THE NURSING DIAGNOSIS AS THE SPECIFIC HEALTH PROBLEM

Front 44

ACTUAL NURSING DIAGNOSIS

Back 44

DESCRIBES HUMAN RESPONSES TO HEALTH CONDITIONS OR LIFE PROCESSES THAT EXIST IN AN INDIVIDUAL OR COMMUNITY

Front 45

RISK NURSING DIAGNOSIS

Back 45

DESCRIBES HUMAN RESPONSES TO HEALTH CONDITIONS OR LIFE PROCESSES THAT HAVE A CHANCE OF DEVELOPING IN A VULNERABLE INDIVIDUAL, FAMILY, OR COMMUNITY

Front 46

WELLNESS NURSING DIAGNOSIS

Back 46

DESCRIBES HUMAN RESPONSES TO LEVELS OF WELLNESS IN AN INDIVIDUAL, GROUP, OR COMMUNITY THAT HAVE A READINESS FOR ENHANCEMENT OR IMPROVEMENT.

Front 47

DIAGNOSTIC LABEL

Back 47

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.

Front 48

RELATED FACTOR

Back 48

A CONDITION OR ETIOLOGY IDENTIFIED FROM THE PT'S ASSESSMENT DATA

Front 49

ETIOLOGY

Back 49

CAUSE OF THE NURSING DIAGNOSIS

Front 50

MIND MAPPING

Back 50

A WAY TO GRAPHICALLY REPRESENT THE CONNECTIONS BETWEEN CONCEPTS (NURSING DIAGNOSIS) THAT ARE RELATED TO A CENTRAL SUBJECT (A PT'S HEALTH PROBLEMS)

Front 51

PLANNING

Back 51

THE 3RD STEP IN THE NURSING PROCESS

Front 52

GOAL

Back 52

A SPECIFIC AND MEASURABLE BEHAVIOR OR RESPONSE THAT REFLECTS THE PT'S HIGHEST POSSIBLE LEVEL OF WELLNESS AND INDEPENDENCE IN FUNCTION

Front 53

EXPECTED OUTCOME

Back 53

A SPECIFIC MEASURABLE CHANGE IN A PT'S STATUS THAT YOU EXPECT TO OCCUR IN RESPONSE TO NURSING CARE

Front 54

SCIENTIFIC RATIONALE

Back 54

REASON

Front 55

NURSE-INITIATED INTERVENTIONS

Back 55

THE INDEPENDENT RESPONSES OF THE NURSE TO A PT'S NURSING DIAGNOSIS AND HEALTH CARE NEEDS

Front 56

PHYSICIAN-INITIATED INTERVENTIONS

Back 56

BASED ON THE PHYSICIAN'S RESPONSE TO TREAT OR MANAGE A MEDICAL DIAGNOSIS

Front 57

COLLABORATIVE INTERVENTIONS

Back 57

THERAPIES THAT REQUIRE THE COMBINED KNOWLEDGE, SKILL AND EXPERTISE OF MULTIPLE HEALTH CARE PROFESSIONALS

Front 58

CONCEPT MAPS

Back 58

A VISUAL REPRESENTATION OF PT. PROBLEMS AND INTERVENTIONS THAT SHOWS THEIR RELATIONSHIPS TO ONE ANOTHER

Front 59

CRITICAL PATHWAYS

Back 59

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

Front 60

IMPLEMENTATION

Back 60

THE FOURTH STEP OF THE NURSING PROCESS THAT INVOLVES THE PROVISION OF CARE TO PT'S

Front 61

NURSING INTERVENTION

Back 61

ANY TREATMENT BASED UPON CLINICAL JUDGMENT & KNOWLEDGE THAT A NURSE PERFORMS TO ENHANCE PT OUTCOMES

Front 62

DIRECT CARE INTERVENTIONS

Back 62

TREATMENTS PERFORMED THROUGH INTERACTION WITH THE PT.

Front 63

INDIRECT CARE INTERVENTIONS

Back 63

TREATMENTS PERFORMED AWAY FROM THE PT BUT ON BEHALF OF THE PT OR GROUP OF PTS. (E.G. SAFETY & INFECTION CONTROL, DOCUMENTATION, INTERDISCIPLINARY COLLABORATION

Front 64

PROTOCOL

Back 64

A WRITTEN PLAN SPECIFYING THE PROCEDURES TO BE FOLLOWED DURING CARE OF PT'S W/ SELECT CLINICAL CONDITION OR SITUATION (EXAMPLE: ADMINISTRATION OF CHEMOTHERAPY)

Front 65

STANDING ORDER

Back 65

A PREPRINTED DOCUMENT CONTAINING ORDERS FOR THE CONDUCT OF ROUTINE THERAPIES, MONITORING GUIDELINES, &/OR DIAGNOSTIC PROCEDURES FOR SPECIFIC PT'S W/ IDENTIFIED CLINICAL PROBLEMS

Front 66

IMPLEMENTATION SKILLS

Back 66

1. COGNITIVE SKILLS
2. INTERPERSONAL SKILLS
3. PSYCHOMOTOR SKILLS

Front 67

DIRECT CARE INCLUDES:

Back 67

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

Front 68

ADVERSE REACTION

Back 68

A HARMFUL OR UNINTENDED EFFECT OF A MEDICATION, DIAGNOSTIC TEST, OR THERAPEUTIC INTERVENTION

Front 69

PREVENTATIVE NURSING ACTIONS

Back 69

PROMOTE HEALTH AND PREVENT ILLNESS TO AVOID THE NEED FOR ACUTE OR REHABILITATIVE HEALTH CARE

Front 70

INDIRECT CARE INCLUDES

Back 70

DELEGATING, SUPERVISING, AND EVALUATING THE WORK OF OTHER STAFF MEMBERS

Front 71

EVALUATION

Back 71

CRUCIAL TO DETERMINE WHETHER AFTER APPLICATION OF THE NURSING PROCESS, A PT'S CONDITION OR WELL-BEING IMPROVES

Front 72

STANDARD OF CARE

Back 72

THE MINIMUM LEVEL OF CARE ACCEPTED TO INSURE HIGH QUALITY OF CARE TO PTS