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53 Cards in this Set
- Front
- Back
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John
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O
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Differentiate the three levels of illness prevention and apply each to clinical situations
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PRIMARY - avoid or delay illness/injury occurrence.
Ex - seat belts SECONDARY - early detection Ex - Pap smear TERTIARY - rehabilitation; goal is to return to best possible function and prevent severe disabilities. |
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Sensory-Security =
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This is the sum of the processes utilized to attain and maintain optimal health in adapting to the changing environment.
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What are the eight core components of the nursing program?
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1- Professional Behaviors
2- Communication 3- Assessment 4- Clinical Decision Making 5- Caring Interventions 6- Teaching and Learning 7- Collaboration 8- Managing Care |
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Self-Concept =
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the sum of the processes by which the individual maintains physical, personal, and interpersonal self in relation to the environment.
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List the Steps of the EVALUATION stage
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1 - Determine goal/outcome
2 - Assess pt. for that expected behavior 3 - Compare goal with exact pt. response 4 - Judge degree to which the goal has been reached |
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Oxygenation-Circulation =
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sum of the processes by which oxygen is delivered to, utilized by and removed from the body cells. It enables body function and is affected by environmental factors.
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Define Values
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Concepts, ideas, behaviors, and significant themes that give meaning to a person's life.
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Nutrition-Metabolic =
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This is the sum of the processes through which requirements for growth are supplied, utilized and eliminated to maintain the internal environment.
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List three things to do after the Nursing Dx
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* Goals need to be set
* Nurse and patient set goals * Include patient |
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Health State of Individual (Page 4, Figure 1-3). Areas to consider...
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Genetic
Cognitive Age Sex Environment/Lifestyle Geographic Location Culture Religion Standard of Living Health Belief/Practices Previous Health Experience Support Systems (formal and informal) |
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What is the most effective medical aseptic practice?
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HANDWASHING
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Define Morals
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standards of rights and wrongs that are often based on religious belief.
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List the three Degrees of Attainment
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1 - Met
2 - Partially met 3 - Not met |
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What is an advance directive?
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written document that allows the patient to make legal decisions about treatment
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List five steps of the IMPLEMENTATION process?
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1 - Reassess the patient
2 - Review and revise care plan 3 - Organize (equipment/personnel) 4 - Prepare (environment/patient and family) 5 - Anticipate and prevent complications |
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False Imprisonment
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Pertinently, holding someone against thier will
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Questions to consider during the PLANNING stage
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1 - What problems need immediate attention?
2 - What problems have simple solutions? 3 - What problems must be referred? 4 - What problems must be recorded on the POC? |
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Define Gross Negligence
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intentional failure to perform a duty in reckless disregard of consequences to the patient.
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What is a "Standing Order"?
What is "Protocol"? |
Standing Order - dictates a situation and prescribes a standardized intervention.
Protocol - a written plan specifying the procedures to be followed during an assessment or when providing treatment for a specific condition. |
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Define Laws
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rules of conduct that protect the social (society) fabric.
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Objective data are obvious, measurable; can be seen, heard, and manipulated. By contrast SUBJECTIVE data tends to be more _________, __________, or ____________.
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Subtle
Covered Hidden |
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Define Criminal Negligence
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Flagrant and reckless disregard for the safety of others and/or disregard to possible injury.
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The 5 assesments
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1.communication skills
2.observation skills 3.assesment skills- BP, T,R,P, AUSCULTION,PALPATION 4.knowing cues vs inference 5.validate impressions |
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What are three components of the Nursing Assessment?
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1 - Data collection
2 - Data validation 3 - Data documentation "If you didn't chart it, you didn't do it." |
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List 5 roles of the nurse.
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Provider
Teacher Manager Member of Profession Advocate |
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Nursing Dx vs. Doctor Dx
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Doctor Dx -
1 - Identifies disease 2 - Treatment of disease 3 - Cure of disease -------------- 1 - Nurse states patient's actual or potential response to disease/disorder 2 - Develop plan of care to adapt to changes from health problems |
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During PLANNING the nurse does what?
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Sets goals; considers desired outcome and identifies appropriate nursing actions
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During ASSESSMENT one
____________ patient _________. |
Identifies
Problems |
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"The nursing process is..."
(three things) |
Systematic
Organized Comprehensive (thorough, ongoing, plans may change to adapt to changing needs) |
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What occurs during the INTERVENTION/IMPLEMENTATION stage of the Nursing Process?
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Perform the identified nursing actions.
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Purpose of 5 step nursing process.
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1 - Establish patient's BASE data
2 - Identify patient's health care needs 3 - Determine priorities of care, goals and expected outcomes 4 - Establishing a nursing care plan |
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During the EVALUATION stage what happens?
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Determine if the goals has been met and if anticipated outcomes have been achieved.
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List 4 aspects of critical thinking
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Active
Organized Cognitive Process |
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Planning includes (6)
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1-Goal Setting/Patient priorities
2-Selecting interventions to achieve patient goals 3-Documenting care plan 4-Consultation with healthcare team 5-Modification of care 6-Recording info about the patient |
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(During) ASSESSMENT (we evaluate what?)
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Evaluate patient's condition
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OBJECTIVE data is informatin that is __________ and ___________.
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Measurable
Observable |
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During DIAGNOSE we IDENTIFY what?
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Patient's problem
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Define "Optimal Health"
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the best level of attainable well-being for a given individual.
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Nursing Diagnosis/Problem Diagnostic Statement
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1 - Problem
2 - Etiology Think Maslow when Prioritizing... 1 - Look for most life threatening 2 - Then problems that interfere normal function/quality of life 3 - Then patient preferences |
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Three characteristics of the Nursing Dx...
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1 - Clear picture of patient problems
2 - Patient response to illness 3 - Distinguishes nurses role vs. doctor's role |
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What is "Holistic Health"?
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Health approach that considers the body, mind, and spirit to be interrelated.
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List three types of nursing orders (interventions)
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1-Interdependent = carried out by nurse in collaboration with another healthcare professional (protocol)
2-Dependent = Based on written order of another professional 3-Independent = You are able to perform as covered by licensure and law |
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Four advantages of Nursing Dx
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1-Efficient care
2 - Actions within standards of nursing practice 3 - Individualized patient care 4 - Goal directed care |
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Nursing Dx
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- Acutal Nursing Diagnosis
* Three Part Statement * Contains P E S * Uses - Risk Nursing Diagnosis * Two part * contains P E * Uses |
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Define "illness"
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A separation from health.
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Define "illness"
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A separation from health.
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List limitations of Nursing Dx (2)
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1 - May become "wordy"
2 - May label patient incorrectly |
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Interventions must be related to the nursing ______?
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Goal
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Patient Goals and Outcome Criteria
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- are long or short term
- have measurable verbs - must be specific in content and time - must be attainable/realistic - are the "P" - Include behavior, criteria, time, and condition |
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Define "Health"
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Condition that allows for the pursuit and enjoyment of desired cultural values; absence of symptoms; level of wellness; not merely the absence of disease or infirmity.
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List the component parts of the three, two, and one part Diagnostic Statement.
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P E S
P E P |
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State the Diagnostic Statement formula
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P r/t E aeb S/S
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