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53 Cards in this Set

  • Front
  • Back
What are the five steps of the nursing process
Assessing, diagnosing, planning, implementing and evaluating
What are the characteristics of the application of the nursing process
Systematic and rational in planning, continuous su-process where the five pases overlap, cyclical and dynamic component follow a logical sequence, goal oriented, client centered, interpersonal and collaborative and universally applicable to any type of client.
What are the skills required for applying the nursing process
Interpersonal skills, technical skills, intellectual skills and accountability and responsibility
What is involved in Assessment
nurse collecting data, organizing data, validating data and documenting data. the accuracy and completeness is important because it effects all the other steps
What are the three steps of documentation.
Nurse collects data about clients health needs from a variety of sources, nurse validates organizes and interprets the data as it applies to the client, documntation of the data must be in a retrievable forms.
What is the purpose of assessment
to establish a database concerning the clients physical, psychosocial, and emotional health for the purpose of identifying health promoting behaviors as well as potential or actual health probems. To gather data on the clients funtional abilities and the absence or presence of dysfunction. to obtain information on the clitns normal activities of daily living, to allow the nurse-client relationship to form
what is comprehensive data
complete health history and current needs assessment to provide baseline client data and nurse can measure against changes in health status
What is focused assessment
limited in scope in order to focus on a particular need or health care concern
What is an Ongoing assessment
systematic follow-up to problems indentified during a comprehensive or focused assessment
Primary source data
information directly from the client using both interview and physical exam
What is secondary source data
data from others, such as family members or other health are providers and medical records
What is subjective data
data from the clients point of view
apparent only to the person affected
clients sensations, feelings, values, beliefs, attitudes, concerns and perceptions of their own health status or ife situation.
What is objective data
Signs, vital signs, observable and measurable data obtained through standard assesssment techniques. measured or tested against acceptable standards
what is health history
review of the clients functional health patterns prior to the current contact with the health care provider provides much of the subjective data
Describe diagnosis or analysis
nurse analyzes data, identifies health problems, risks and strengths and formulates a diagnostic statement. provides the basis for client care
What are the steps of diagnosing and analyzing data
nurse analyzes data to identify actual, potential and possile nursing diagnoses. Nurse writes client's actual or potential health problems as nursing diagnostic statements. nurse validates the diagnosis for the specific client
Describe validating data
prevents omissions, misunderstandings and incorrect inferences and conclusions. Any grossly abnormal findings should be validated
What is data clustering
cluster collected data into groups of related pieces in order to help identify areas of the clients problems and strengths. Helps distinguish between relevant and irrelevant data.
What is the firs component of the nursing diagnosis
problem statement or diagnostic label. it describes the client's response to an actual or potential health problem or wellness condition
What is the second component of the nursing diagnosis
etiology that is the related cause or contributor to the problem and is linked to the terminology r/t
what is the third component of the nursing diagnosis
defining characteristics also known as the signs and symptoms, subjective and objective data, or clinical manifestations. joined to the first two components with the connecting phrase "as evidenced by" or AEB
what are the three categories of nursing diagnoses
actual nursing diagnosis when problem exists.
risk nursing diagnosis concerns a potential problem that does not yet exist but their are risk factors present. Wellness nursing diagnosis indicates an expression of a desire to attain higher level of wellness.
How are nursing diagnoses prioritized
Using maslow's heirarchy of needs, consider life threatening first, basic physiology needs, then safety stability affection and then self worth
What are the steps of planning
prioritize problems or diagnosis.
establish goals or expected outcomes.
aim nursing interventions at achieving goals and develop a plan of care.
develop outcome criteria by which goals can be measured.
delegate nuring activities to appropriate health care team members.
What is initial planning
initial planning, development of preliminary poc by the nurs who performs the admission
What is ongoing planning
continuous updating of the client's plan of care. poc may be revised as new info about the client is gathered and evaluated
What is discharge planning
critical anticipation and planning for the client's needs after discharge
What does outcome identification come from
establishment of goals and expected outcomes for each nursing diagnosis
What is the purpose of goals or outcomes
provide guidelines for individualized nursing interventions and establish evaluation criteria to measure the effectiveness of the poc
Define goals
broad statements that describe the intended or desired change in te clint's condition or behavior. they refer to the diagnostic label or problem statement of the nursing diagnosis
How are client centered goals obtained
nurse collaborates with the client or family members to ensure nursing care is individualized and focused on the client
What are short term goals
objective statements that outline a desired resolution of the nursing iagnosis over a short period, usually a few ours or day. focus on etiology component of the nursing diagnosis.
What are long term goals
objective statements that outline desired resolution of nsg. diagnosis over a longer period, usually weeks or months.
What is done after goals are established
nurse identifies expected outcomes that are detailed specific statements that describe the methods through which the goals will be achieved and include aspects of direct nsg. care, teaching and continuity of care.
expected outcomes must be
measurable, time limited and realistic.
What are nursing interventions
actions performed or delegated by the nurse that help the client achieve the results specified by the goals and expected outcomes.
What are the characteristics of nursing intervention
individualized and stated in specific terms
Where are nursing interventions documented
in the nursing plan of care
What is an Independent nursing intervention.
Actions the nurse initiates and do not require direction or an order from another health care professional and include adl's, health promotion and counseling interventions
What are interdependent nursing interventions
Interventions implemented in collaboration with other health care professionals.
What are dependent nursing interventions
interventions tht require and order by aphysician or another health care provider.
What factors r/t the client are considered in writing a care plan
clients health status, sex, age, individual peferences, physical condition, cultural and spiritual beliefs, environmental factors and psychological factors.
What are protocols
a series of standing orders or procedures that the nurse follows under certain specific conditions. defines permissible interventions and any circumstances that allow the nurse to implement the measures indentified in the protocol
What is the nursing practice act
statute enacted by legislature of the state outlines the scope of nursing practice in that state.
What is implementation
execution of the nursing care plan
what does implementation require of the nurse
reassess the client, determine the nurses need for assist, implemet the nursing intervention, supervise delegated care and document nursing activities.
what documentation is important in evaluating the implemented intervention
document data about client's condition prior to the intervention, response to the intervention and the outcome
What should documentation include
objective, descritive and complete data and should include observations no opinions
what is delegation
transferring selected nursing tasks to licensed personnel who are competent to perform that specific tasks.
What is the nurse responsible for in a delegated task
accountable for appropriate delegation and supervision of care. responsible to evaluate the ability of the person delegated to perform the task by assessing his or her knowledge and understanding of it. delegate tasks with direction of what to report and how to carry them out
What is evaluating
continuous nursing function, the nurse measures the effectiveness of the total nursing process
What does the nurse do if the goal is met
either terminate care fo that goal or continue to maintain status
what are some possible reasons the client did not meet their goals
initial assessment data incomplete.
goals and outcomes were not realistic for the client.
time frame was not appropriate.
Goals or interventions were not appropriate for the client or his situation