Nc1 Unit One

Front 1

What are the five steps of the nursing process

Back 1

Assessing, diagnosing, planning, implementing and evaluating

Front 2

What are the characteristics of the application of the nursing process

Back 2

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.

Front 3

What are the skills required for applying the nursing process

Back 3

Interpersonal skills, technical skills, intellectual skills and accountability and responsibility

Front 4

What is involved in Assessment

Back 4

nurse collecting data, organizing data, validating data and documenting data. the accuracy and completeness is important because it effects all the other steps

Front 5

What are the three steps of documentation.

Back 5

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.

Front 6

What is the purpose of assessment

Back 6

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

Front 7

what is comprehensive data

Back 7

complete health history and current needs assessment to provide baseline client data and nurse can measure against changes in health status

Front 8

What is focused assessment

Back 8

limited in scope in order to focus on a particular need or health care concern

Front 9

What is an Ongoing assessment

Back 9

systematic follow-up to problems indentified during a comprehensive or focused assessment

Front 10

Primary source data

Back 10

information directly from the client using both interview and physical exam

Front 11

What is secondary source data

Back 11

data from others, such as family members or other health are providers and medical records

Front 12

What is subjective data

Back 12

data from the clients point of view
symptoms
apparent only to the person affected
clients sensations, feelings, values, beliefs, attitudes, concerns and perceptions of their own health status or ife situation.

Front 13

What is objective data

Back 13

Signs, vital signs, observable and measurable data obtained through standard assesssment techniques. measured or tested against acceptable standards

Front 14

what is health history

Back 14

review of the clients functional health patterns prior to the current contact with the health care provider provides much of the subjective data

Front 15

Describe diagnosis or analysis

Back 15

nurse analyzes data, identifies health problems, risks and strengths and formulates a diagnostic statement. provides the basis for client care

Front 16

What are the steps of diagnosing and analyzing data

Back 16

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

Front 17

Describe validating data

Back 17

prevents omissions, misunderstandings and incorrect inferences and conclusions. Any grossly abnormal findings should be validated

Front 18

What is data clustering

Back 18

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.

Front 19

What is the firs component of the nursing diagnosis

Back 19

problem statement or diagnostic label. it describes the client's response to an actual or potential health problem or wellness condition

Front 20

What is the second component of the nursing diagnosis

Back 20

etiology that is the related cause or contributor to the problem and is linked to the terminology r/t

Front 21

what is the third component of the nursing diagnosis

Back 21

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

Front 22

what are the three categories of nursing diagnoses

Back 22

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.

Front 23

How are nursing diagnoses prioritized

Back 23

Using maslow's heirarchy of needs, consider life threatening first, basic physiology needs, then safety stability affection and then self worth

Front 24

What are the steps of planning

Back 24

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.

Front 25

What is initial planning

Back 25

initial planning, development of preliminary poc by the nurs who performs the admission

Front 26

What is ongoing planning

Back 26

continuous updating of the client's plan of care. poc may be revised as new info about the client is gathered and evaluated

Front 27

What is discharge planning

Back 27

critical anticipation and planning for the client's needs after discharge

Front 28

What does outcome identification come from

Back 28

establishment of goals and expected outcomes for each nursing diagnosis

Front 29

What is the purpose of goals or outcomes

Back 29

provide guidelines for individualized nursing interventions and establish evaluation criteria to measure the effectiveness of the poc

Front 30

Define goals

Back 30

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

Front 31

How are client centered goals obtained

Back 31

nurse collaborates with the client or family members to ensure nursing care is individualized and focused on the client

Front 32

What are short term goals

Back 32

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.

Front 33

What are long term goals

Back 33

objective statements that outline desired resolution of nsg. diagnosis over a longer period, usually weeks or months.

Front 34

What is done after goals are established

Back 34

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.

Front 35

expected outcomes must be

Back 35

measurable, time limited and realistic.

Front 36

What are nursing interventions

Back 36

actions performed or delegated by the nurse that help the client achieve the results specified by the goals and expected outcomes.

Front 37

What are the characteristics of nursing intervention

Back 37

individualized and stated in specific terms

Front 38

Where are nursing interventions documented

Back 38

in the nursing plan of care

Front 39

What is an Independent nursing intervention.

Back 39

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

Front 40

What are interdependent nursing interventions

Back 40

Interventions implemented in collaboration with other health care professionals.

Front 41

What are dependent nursing interventions

Back 41

interventions tht require and order by aphysician or another health care provider.

Front 42

What factors r/t the client are considered in writing a care plan

Back 42

clients health status, sex, age, individual peferences, physical condition, cultural and spiritual beliefs, environmental factors and psychological factors.

Front 43

What are protocols

Back 43

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

Front 44

What is the nursing practice act

Back 44

statute enacted by legislature of the state outlines the scope of nursing practice in that state.

Front 45

What is implementation

Back 45

execution of the nursing care plan

Front 46

what does implementation require of the nurse

Back 46

reassess the client, determine the nurses need for assist, implemet the nursing intervention, supervise delegated care and document nursing activities.

Front 47

what documentation is important in evaluating the implemented intervention

Back 47

document data about client's condition prior to the intervention, response to the intervention and the outcome

Front 48

What should documentation include

Back 48

objective, descritive and complete data and should include observations no opinions

Front 49

what is delegation

Back 49

transferring selected nursing tasks to licensed personnel who are competent to perform that specific tasks.

Front 50

What is the nurse responsible for in a delegated task

Back 50

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

Front 51

What is evaluating

Back 51

continuous nursing function, the nurse measures the effectiveness of the total nursing process

Front 52

What does the nurse do if the goal is met

Back 52

either terminate care fo that goal or continue to maintain status

Front 53

what are some possible reasons the client did not meet their goals

Back 53

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