Foundations Of Nursing

Front 1

Nursing Process

Back 1

a systematic problem solving approach toward giving individualized nursing care

Front 2

6 steps of Nursing Process
(ADOPIE)

Back 2

1. Assessment
2. Diagnosis
3. Outcome Identification
4. Planning
5. Implementation
6. Evaluation

Front 3

Characteristics of Nursing Process

Back 3

- It is a framework for providing nursing care to individuals, families, and communities
- It is orderly and systematic
- It is interdependent
- Provides specific care for individuals, families, and communities
- Patient centered, using the patient's strengths
- Appropriate for use throughout the lifespan
- It can be used in all settings

Front 4

Assessment

Back 4

- refers to the evaluation or appraisal of a patient's health state
- The systematic collection of subjective and objective data

Front 5

Primary source

Back 5

- the patient themself

Front 6

Secondary source

Back 6

- family members, significant others, other health care professionals, health records, and literaturereview

Front 7

Diagnostic Reasoning

Back 7

Process of gathering and clustering data to draw inferences and propose diagnoses

Front 8

Diagnosis

Back 8

- 2nd phase in nursing process
- The clinical act of identifying problems

Front 9

Nursing Diagnosis

Back 9

- describes an individual, family, or group response to an actual or potential health problem
- Provides the basis for selection of nursing interventions to achieve positive patient outcomes

Front 10

Diagnostic Process Steps set by NANDA-I

Back 10

1. Recognize the existence of cues
2. Generate possible diagnoses
3. Compare cues to possible diagnoses
4. Conduct a focused data collection
5. Validate diagnoses

Front 11

Critical Thinking

Back 11

- a self-guided, self-disciplined thinking that attempts to reason at the highest level of quality in a fair-minded way

Front 12

Importance of Critical Thinking in Nursing

Back 12

Critical thinking helps nurses to choose solutions or identify options for patient care situations
Takes us through a process in order to make decisions

Front 13

Skills in Providing Care

Back 13

Listening
Collaborating
Communicating

Front 14

Critical thinking and Examinations

Back 14

Interpret
Analyze
Outcomes
Evaluate
Infer
Explain

Front 15

According to the ANA Scope and Standards of Practice
Outcome Identification refers to ______?

Back 15

- formulating and documenting measurable, realistic, patient-focused goals.

Front 16

Critical thinking and Examinations

(ADOPIE)

Back 16

A - Interpret
D- Analyze
O- Outcome
P- Evaluate
I- Infer
E- Explain

Front 17

Interpret

Back 17

- Ask relevant questions and explore ideas
- Validate data
- Recognize issues and concerns

Front 18

Analyze

Back 18

- Interpret evidence
- Consider viewpoints and recognize assumptions
- Identify missing information

Front 19

Outcome

Back 19

- Results that are measurable and observable

Front 20

Evaluate

Back 20

- Detect bias
- Consider legal/ethical standards
- Use reflective skepticism
- Examine alternatives
- Judge worth of evidence

Front 21

Infer

Back 21

- Predict consequences
- Apply deductive/inductive reasoning
- Support conclusions with evidence
- Set priorities
- Plan approaches
- Modify/ individualize interventions
- Apply research in practice

Front 22

Explain

Back 22

- Determine outcome attainment
- Revise Plans
- Identify client's perception of results

Front 23

Assessment is done for what reasons?

Back 23

- to establish baseline info. on the patient
- To determine the patient's normal function
- the patients risk of dysfunction
- the patient's strengths
- To provide data for the diagnosis phase

Front 24

The following activities make up the assessment phase:

Back 24

- Collection of Data
- Validation of Data
- Organization of Data

Front 25

4 Types of Assessment

Back 25

1. Admission Assessment
2. Focus Assessment
3. Time-Lapse Assessment
4. Emergency Assessment

Front 26

Admission Assessment

Back 26

- Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction
- baseline for reference and future comparison

Front 27

Focus Assessment

Back 27

- Status determination of a problem identified during previous assessment
- Ongoing process, few minutes to a few hours

Front 28

Time-lapse Assessment

Back 28

- Comparison of patient's current status to baseline obtained earlier
- 3,6, or 9 months between assessments

Front 29

Emergency Assessment

Back 29

- Identification of life-threatening situation
- Occurs anytime a physiologic, psychological, or emotional crisis occurs

Front 30

Assessment Skills

Back 30

- Observation
- Interviewing
- Physical Examination

Front 31

Observation includes:

Back 31

- Vision - Objective
- Smell - Objective
- Hearing - Sub. and Objective
- Touch - Objective

Front 32

4 Phases of Interviewing

Back 32

Preparatory phase
Introductory phase
Maintenance phase
Concluding phase

Front 33

Physical examination techniques

Back 33

Inspection
Palpation
Percussion
Auscultation

Front 34

Observation is:

Back 34

- The act of noticing patient cues

Front 35

Interviewing is:

Back 35

- Integration and communication process for gathering data by questioning and information exchange

Front 36

Physical Examination is:

Back 36

- Analysis of bodily functioning using the techniques of inspection, palpation, percussion, and auscultation

Front 37

Definitions for Classification of Nursing Diagnoses
(Domain)

Back 37

A sphere of activity, concern, or function; a field: the domain of history

Front 38

Definitions for Classification of Nursing Diagnoses
Class

Back 38

A set, collection, group, or configuration containing members regarded as having certain attributes or traits in common; a kind or category.

Front 39

Nursing diagnoses and other healthcare problems

Back 39

Nursing diagnosis
Medical diagnosis
Collaborative health problems

Front 40

Components of a Nursing Diagnosis

Back 40

Diagnostic label
Descriptors
Definition
Related factors
Defining characteristics
Risk factors

Front 41

Descriptors Used by NANDA-I

Back 41

Anticipatory
Compromised
Decreased
Deficient
Delayed
Disproportionate
Disabled
Disorganized
Disturbed
Dysfunctional
Effective
Excessive

Front 42

Diagnosis Activities

Back 42

Identify pattern
Validate diagnosis
Formulate the diagnostic statement

Front 43

Diagnosis Activities
Identify pattern

Back 43

Cue clustering
Problems in cue clustering
Cluster interpretation
Problems in cluster interpretation

Front 44

Diagnosis Activities
Validate diagnosis

Back 44

Problems in diagnostic validation

Front 45

Diagnosis Activities
Validate diagnosis

Back 45

Problems in diagnostic validation

Front 46

Diagnosis Activities
Formulate the diagnostic statement

Back 46

Actual nursing diagnosis
Risk nursing diagnosis
Wellness nursing diagnosis
Possible nursing diagnosis

Front 47

3 types of nursing Diagnoses

Back 47

- Actual Nursing Diagnosis
- Risk Nursing Diagnosis
- Wellness Diagnosis

Front 48

Actual Nursing Diagnosis

(3 Parts)

Back 48

- Diagnostic Label
- Related Factors
(etiology)
- Defining Characteristics
(signs and symptoms)

Front 49

Example of an Actual Nursing Diagnosis

Back 49

Stress Urinary Incontinence R/T
weak pelvic muscles, obesity, and gravid uterus as evidenced by urine dribbling when coughing

Front 50

Risk Diagnosis
(2 parts)

Back 50

- Diagnostic label R/T
- Risk factors

Front 51

Example of Risk Diagnosis

Back 51

- Risk for Caregiver Role Strain R/T
discharge of family member with significant health needs, economic instability, lack of respite care availability

Front 52

Wellness Diagnosis

(1 Part)

Back 52

- Diagnostic Label

Front 53

Example of Wellness Diagnosis

Back 53

- Potential for Enhanced Parenting

Front 54

Functional Health Patterns of Nursing Diagnosis

Back 54

- Health Perception- Health Management
- Activity-Execise
- Nutritional-Metabolic
- Elimination
- Sleep-Rest
- Cognitive-perceptual
- Self-Perception
- Role-Relationship
- Coping-stress Tolerance
- Sexuality-Reproductive
- Value-Belief

Front 55

Outcome Identification

Back 55

- is the formulation of goals and measurable outcomes that provide the basis for evaluating nursing diagnoses

Front 56

Outcome Identification

Purposes

Back 56

Providing individualized care
Promoting patient participation
Planning care that is realistic and measurable
Allowing for involvement of support people

Front 57

Outcome Identification

Activities

Back 57

Establish priorities
Establish patient goals and outcome criteria

Front 58

Outcome Identification Activities
3 Priorities Established

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High priority
Medium priority
Low priority

Front 59

High Priority Nursing Diagnosis

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- Any Life threatening situation
needs immediate attention

Front 60

Medium Priority Nursing Diagnosis

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- involve problems that could result in unhealthy consequences such as physical or emotional impairment, but are not likely to threaten life

Front 61

Low Priority Nursing Diagnosis

Back 61

- involve problems that usually can be resolved easily with minimal interventions and have little potential to cause significant dysfunction

Front 62

Nursing Outcomes Classification
(NOC) are organized how?

Back 62

- Organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes

Front 63

Outcome Identification

Objectives

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- Establish priorities
- Establish client goals and outcome identification

Front 64

A patient outcome is

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- an educated guess, made as a broad statement, about what the patient's state will be after the nursing intervention is completed

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Qualifier

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- description of the parameter for achieving the outcome

ex. "Ambulates safely with one-person assistance"

Front 66

Outcomes may be ____ or ____?

Back 66

- short-term or Long-term

Front 67

Outcome criteria
3 characteristics of

Back 67

Specific, measurable, realistic

Front 68

Outcome criteria answer the questions ____, ____, ____, ____, and ____?

Back 68

- Who; what actions; under what circumstances; how well; and when

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Requirements for outcome criteria are....

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- Subject: Who is the person to achieve the goals
- Verb: What actions must the person do to achieve the goals
- Condition: Under what circumstances is the person to perform the action?
- Criteria: How well is the person to perform the action?
- Specific Time: When is the person expected to perform the action?

Front 70

Purposes of Planning include ???

Back 70

- Direct patient care activities
- Promote continuity of care
- Focus charting requirements
- Allow for delegation of specific activities

Front 71

Planning is the ___ phase of of the nursing process?

Back 71

- 4th

Front 72

Def of Planning

Back 72

-refers to the development of nursing strategies designed to ameliorate patient problems

Front 73

Nursing Intervention Classification
(NIC) are organized in three level taxonomy consisting of ????

Back 73

- domains, classes, and interventions

Front 74

Taxonomy of NIC includes these 7 domains???

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1. Physiologic: Basic
2. Physiologic: Complex
3. Behavioral
4. Safety
5. Family
6. Health system
7. Community

Front 75

Each NIC domain contains

Back 75

- classes which are groups of interventions that are broken down into individual interventions.

Front 76

Planning nursing interventions

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Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient outcomes

Front 77

Types of Nursing Interventions Include

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Psychomotor- Technical
Psychological- Interpersonal
Educational- Cognitive
Maintenance-Technical
Surveillance- Technical
Supervisory- Cognitive
Sociocultural- Interpersonal

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Psychomotor Interventions

Back 78

- positioning, inserting, applying

Front 79

Psychological

Back 79

Interpersonal

supporting, exploring, encouraging

Front 80

Educational

Back 80

Cognitive
demonstrating, teaching, observing return demonstrations

Front 81

Maintenance

Back 81

Technical
skin care, hygiene

Front 82

Surveillance

Back 82

Technical

detecting changes

Front 83

Supervisory

Back 83

Cognitive

other healthcare providers

Front 84

Sociocultural

Back 84

Interpersonal

spending time, incorporating cultural differences into care regimen

Front 85

Writing a patient plan of care must be

Back 85

Patient centered
Step-by-step process

Front 86

A patient plan of care documents

Back 86

- the problem solving process.

Front 87

Patient care Plans must be

Back 87

- written by a RN
- be documented in the patients health record
- must reflect the standards of care established by the institution and profession

Front 88

Two important concepts guide a patient plan of care. They are:

Back 88

- the care plan is patient centered
- The plan of care is a step by step process

Front 89

Writing a patient plan of care
Step-by-step process is evidenced by

Back 89

- sufficient data are collected to sustantiate nursing diagnosis
- at least one goal must be stated for each nursing diagnosis
- Outcome criteria must be identified for each goal
- Nursing interventions must be specifically designed to meet the intended goal
- Each intervention should be supported by scientific rationale
- Evaluation must address whether each goal was completely met, partially met, or completely unmet

Front 90

3 Types of Patient Plans of Care

Back 90

Instructional patient plans of care
Instructional concept maps
Clinical plans of care

Front 91

Types of Clinical Plans of Care

Back 91

Individual Plan of Care
Standardized Plan of Care
Generic Plan of Care
Computerized Plan of Care

Front 92

Instructional patient plans of care

Back 92

- allow students to demonstrate their knowledge of a variety of patient problems and apply the processes nurses use to solve them

Front 93

Components of instructional patient plans of care

Back 93

- nursing diagnoses
- patient goals
- outcome criteria,
- nursing interventions
- scientific rationale
- evaluation

Front 94

Individual Plan of Care

Back 94

- Written for each patient by an RN
- Nursing Diagnoses are listed
- Specific Goals and interventions to resolve the problem
- Time consuming

Front 95

Standardized Plan of Care

Back 95

- Written by groups of Nurses who are experts in a given area of practice
- Written for a patient population with specific medical diagnosis

Front 96

Generic Plan of Care

Back 96

- Written for specific nursing diagnosis
- Contain the most commonly seen goals and interventions for a particular nursing diagnosis

Front 97

Computerized Plan of Care

Back 97

- generated from assessment data entered into a computer about a specific patient
- Written by experts in the area
- Nurse may customize for the patient once on the screen
- All patient info must be entered into the computer

Front 98

Implementation Activities of implementation

Back 98

Reassessing
Setting priorities
Performing nursing interventions
Recording nursing actions

Front 99

Implementation refers to

Back 99

- the action phase of the nursing process
- It is the actual initiation of the plan and recording the of nursing actions

Front 100

Intellectual skills used in implementation are

Back 100

- problem solving
- decision making
- and teaching

Front 101

Interpersonal skills used in implementation

Back 101

- Verbal and nonverbal communication skills

Front 102

Priorities are set based on what factors

Back 102

- The patient's condition
- New information from reassessment
- Time and resources available for nursing interventions
- Feedback from the patient, family, and healthcare staff
- The nurse's experience in assessing situations and setting priorities

Front 103

Advantages to NIC

Back 103

- Creation of a standardized language that promotes better understanding and communication of nursing interventions
- Expansion of knowledge about similarities and differences across nursing diagnoses
- Exploration of nursing care information systems
- Assistance in determining cost of services that nurses provide
- Demonstration of the impact nurses have within the healthcare system