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64 Cards in this Set

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When is the nursing process used?
whenever client care is provided....whenever the client and nurse come together
The nursing process is a method for organizing and _____________ nursing care based on ____________________.
delivering

problem-solving principles
The nursing process is a method used by nurses to expedite diagnosis and treatment of ____________ and _____________ health problems.
actual and potential health problems
What are the advantages to the patient when a nurse uses the nursing process?
improved quality of care & quality of life

continuity of care

participation in his/her own care

speeds up diagnosis and treatment

creates cost effective plan (both in terms of human suffering and monetary expense)

has precise documentation
The nursing process has tailored interventions for the ____________________ not the ____________.
individual, not the disease
Who first introduced the nursing process?
Lydia Hall in 1955
The first four steps of the process left out __________ until 1973. Then in 1991, ANA identified _____________as the sixth step.
diagnosis

outcome identification
What are the steps to the nursing process?
Assessment
Diagnosis
Planning
Interventions
Evaluation
ADPIE
What are the three important things that are vital for a nursing process to work?
1. Knowledge and Critical Thinking
2. Skills
3. Caring
What are the kinds of assessments?
initial assessment

&

on-going assessment
What is another name for initial assessment?
baseline assessment
data base assessment
comprehensive assessment
What do initial assessments focus on?
all body systems, overall picture of health.
When do you take an initial assessment?
when you first meet them
What is an inital assessment used for?
used to make inital problem list
What is inital assessment concerned with?

Who can do it?
client's overall health status
**it has MULTIPLE DATA VARIABLES


has to be RN
Give an example of a comprehensive assessment tool.

Give an example of a comprehensive assessment.
med/surg tool


nursing history
physician's initial history
physical exam
An on going assessment is also called a _________________. And it can be further divided into:

A)
B)
Focused Assessment

A) trend assessment
B) decision assessment
If you are asking questions such as:

What are your symptoms?
Are you taking any meds that might be causing this?

What type of assessment are you doing?
focused assessment (aka: ongoing assessment)
This assessment is done at every shift.
trend assessment

(focused on specific category, problem or particular area of the body or body system)
Why do you do a trend/focused assessment on every shift?
because you are trying to evaluate the status of existing problems and identify new problems.
This assessment is to gather a bunch of data.
Data base assessment
(type of initial assessment)
This assessment is done to ID any new problems that may have arisen.
Focused assessment: trend assessment
What is a primary data source?

What is a secondary data source?
patient - primary

textbooks- secondary
A panic assessment is an example of this type of assessment.
decisional assessment
What are the components of assessment?
A. Data Collection
B. Data Validation
C. Data Organization
D. Data Analysis
E. Data Reporting/Recording
In which ways can you collect data? Give three examples:
observation
interviewing
physical assessment (inspection, palpation, percussion, ausculatate)
Subjective and Objective data act as ________.
Cues - hints or reminders that prompt you to suspect a problem.
Subjective data is _________.

Objective data is _________.
Subjective = stated

Objective = observed
When you take cues and draw a conclusion, what are you doing?
infering.....which is only as good as the person inferring.
What things can help a nurse identify significant cues and make correct inferences?
1. observational skills
2. nursing knowledge
3. clinical expertise
4. values and beliefs (which could be bad b/c you could be making judgements)
What type of data can be accepted as factual?
data that can be measured accurately...(height, weights, lab study results)
Why do you need to cluster data?
to get a clear picture of health status.

Cluster it according to purpose.
What type of organizational systems focus on medical models?
head to toe
body systems
How do WE organize information?
Doenges/Moorhouse

nursing models helps you see nursing problems, medical models helps you see medical problems
How do you organize information in order to prioritize?
according to Maslow's priority of needs

**you can organize or cluster your data a couple of different ways because each way will reveal different data.
If you cluster according to body systems, you will reveal.....
medical problems
Data analysis can also be called:
identifying patterns, testing first impressions
When you analyze correctly, the most important thing you do is.....
recognize strengths
When you identify appropriate interventions after correctly analyzing data, what is important about these interventions?
that they are individualized
What is the big difference between the nursing model and the medical model when it comes to analyzing data?
with nursing model, you identify strengths too...in medical model you only focus on problems
What is the first step to making a diagnosis?
analyzing
In our program, analyzing data is part of what step of the nursing process?
assessment, but it can be part of nursing diagnosis in other programs
What type of problems should be identified in a nursing diagnosis?
problems the nurse can legally prescribe definitive interventions independently
Who is responsible for initiating a plan to treat the problems identified in a nursing diagnosis?
the nurse is soley accountable
What words do you avoid when writing a nursing diagnosis?
As evidenced by
What is the purpose of a nursing diagnosis?
provides a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable.
What is a second purpose of the nursing diagnosis?
to clarify the exact nature of the problems and risk factors you need to address to achieve the overall expected outcomes of care.
What does diagnose and treat (DT) require you to do?
wait for evidence of problems before beginning treatment.
What does PPMP approach require you to do?
with known problems PREDICT the most common and most dangerous complications and take immediate action to PREVENT them and MANAGE THEM

Then you PROMOTE optimum function, independence and well being
Actual and potential problems
diagnosis
Specific treatments or actions needed to prevent, resolve or manage actual and potential problems
interventions
Specific data that is observed in the patient to show that he or she has benefited from care.
outcome (goal?)
If you are competent, you have.......
the knowledge and skills to identify problems and risks and to perform actions safely and efficiently in various situations.
If you are qualified you have.....
the authority to perform an action or give a professional opinion.
What is a definitive intervention?
the most specific action or tx required to prevent, resolve or manage a health problem.

ex: abx for pneumonia (although a lot of other things would help, without the abx, you won't get very far in the tx)
signs
observable objective data

ex: rashes and fever
symptoms
subjective data

ex: pain and fatigue
cues
signs and symptoms that prompt you to suspect a problem or potential problem
A definitive diagnosis clearly identifies these two things...
the problem and the cause
What is the main focus of the nursing diagnosis?
the IMPACT of the disease, trauma or life change

ADLs

Quality of life issues
Which diagnosis has two parts to its statement?
actual diagnosis
risk diagnosis
Which diagnosis only has one part to its statement?
wellness diagnosis
What are the only two nursing diagnosis that are equal to medical dx?
hypothermia
hyperthermia
What four things does planning involve?
1. setting priorities
2. establishing outcomes/goals
3. determining nursing interventions
4. ensuring the plan is adequately recorded