Nursing Process

Front 1

nursing process

Back 1

systematic
-assess to determine need
-nursing diagnoses
-expected outcomes and plan of care
-implement
-evaluate

Front 2

nursing process enables the nurse and pt to accomplish the following

Back 2

-systematically collect pt data (assessing)
-clearly identify pt strengths and actual and potential problems (diagnoses)
-develop a holistic plan of care and related outcomes and the nursing interventions most likely to assiste the pt.
-execute the plan of care
-evaluate

Front 3

characteristics of nursing process

Back 3

-systematic
-dynamic
-interpersonal
-outcome orientated
-universally applicable in nursing situations

Front 4

trial-and-error problem solving

Back 4

testing any number of solutions until one is found that works.
-not recommended for nursing practice

Front 5

scientific problem solving

Back 5

systematic, seven-step, problem solving.
1-identification
2-data collection
3-hypothesis
4-plan of action
5-hypothesis testing
6-interpretation of results
7-evaluation

Front 6

blended skills (4)

Back 6

-cognitive skills/critical thinking
-technically skilled nurses
-interperonsal skills
-ethical/legal skills

Front 7

standards for critical thinking

Back 7

-clear
-precise
-specific
-accurate
-relevant
-plausible
-consistent
-logical
-deep
-broad
-complete
-significant
-adequate for the purpose
-fair

Front 8

concept mapping

Back 8

used to promote critical thinking about pt problems and treatment.
1. develop a basic skeleton diagram
2. analyze and categorize data
3. analyze nursing diagnoses relationship.
4. identify goals, outcomes, and interventions.
5. evaluate pt's responses.

Front 9

database

Back 9

all the pertinent pt info collected by teh nurse and other healthcare professionals.

Front 10

initial assessment

Back 10

performed shortly after the pt is admitted.
purpose is to establish a complete database for problem identification and care planning.

Front 11

focused assessment

Back 11

data about a specific problem that has already been identified.

Front 12

emergency assessment

Back 12

when a physiologic or psychological crisis presents.
identify life-threatening problems.

Front 13

time-lapsed assessment

Back 13

scheduled to compare a pt's current status to baseline data obtained earlier.

Front 14

minimum data set

Back 14

specifies the info that must be collected from every pt.
nursing assessment guides are based on holistic models rather than medical models.

Front 15

characteristics of data

Back 15

-complete
-factual and accurate
-relevant

Front 16

nursing history

Back 16

-subjective
identify pt's strengths and weaknesses, health risks, potential and existing health problems.
-focuses on getting to knwo the person. followed by nursing physical assessment

Front 17

components of nursing history

Back 17

-profile=age, sex, marital
-reason for seeking care
-normal health habits/patterns
-cultural considerations (diet, activities, decision making)
-current state of health, functioning of body systems, degree of pain
-perceptions
-developmental history, family hisotry
-educational needs

Front 18

Interview-four phases

Back 18

1. preparatory; nurse prepares to meet pt.
2. introduction
3. working phase: gathers all the info for the subjective database.
4. termination

Front 19

nursing physical assessment

Back 19

objective data. normally follows the nursing history and interview.

Front 20

cue

Back 20

subjective and objective data you identify

Front 21

diagnosis-purpose

Back 21

1. identify how an individual, group, community responds to actual or potential health and life processes
2. identify factors that contribute to or cause health problems (etiologies)
3. identify resources or strengths

Front 22

nursing types of problems

Back 22

-promoting safety and preventing harm; detecting and controlling risks
-monitoring for changes in health status
-identifying and meeting learning needs.
-tailoring trtment and meds regimens
-promoting comfort and managing pain.
-promoting health and sense of well-being
-recognizing and addressing problems that impede health
-determining human responses

Front 23

data cluster

Back 23

grouping of pt data or cues that points to the existence of a pt health problem.
nursing diagnoses should always be derived from clusters of significant data rather than from a single cue.

Front 24

no problem?

Back 24

-no nursing response is indicated
-reinforce pt's health habits and patterns
-initiate health-promotion activities to prevent disease or illness
-wellness diagnosis might be indicated.

Front 25

formulation of diagnosis (structure)

Back 25

problem, etiology, defining characteristics.

Front 26

actual nursing diagnosis

Back 26

a problem that has been validated by the presence of major defining characteristics

Front 27

risk nursing diagnosis

Back 27

clinical judgments that an individual, family, community is more vulnerable to develop the problem than others.

Front 28

possible nursing diagnosis

Back 28

statements describing a suspected problem for which additional data are needed.
-potential, risk for impaired skin integrity.
-possible, possible chronic low self-esteem.

Front 29

wellness diagnosis

Back 29

clinical judgments about pt in transition from a specific level of wellness to a higher level of wellness.
Two cues must be present for a valid wellness diagnosis:
1. a desire for a higher level of wellness.
2. an effective present status or function.
related factors aren't included:
-readiness for enhanced family coping.

Front 30

syndrome nursing diagnoses

Back 30

comprise a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation; for example, Rape Trauma Syndrome or Post-trauma Syndrome.

Front 31

Maslow's hierarchy of human needs

Back 31

1. physiologic
2. safety
3. love and belonging
4. self-esteem
5. self-actualization

Front 32

guidelines for writing outcomes

Back 32

-each set of outcomes is derived from only one diagnosis
-at least 1 shows direct resolution of the problem
-are necessary
-pt and family value the outcomes.
-categorized according to type of change they describe: cognitive, psychomotor, affective
-brief and specific-time line
-supportive of the total treatment plan

Front 33

1st part of nursing diagnosis suggests what?

Back 33

suggests pt goals/outcomes

Front 34

2nd part of the nursing diagnosis suggests what

Back 34

suggests nursing interventions

Front 35

nurse-initiated interventions/independent nursing actions

Back 35

nurse-prescribed interventions resulting from their assessment of pt needs.

Front 36

protocols

Back 36

written plans that detail the nursing activities to be executed in specific situations.

Front 37

standing orders

Back 37

protocol:
empower the nurse to initiate actions that ordinarily require the order or supervision of a MD.

Front 38

types of outcomes

Back 38

1. cognitive outcomes
2. psychomotor outcomes: pt's achievement of new skills
3. affective outcomes: changes in pt values, beliefs, and attitudes
4. physiologic outcomes: physical changes.

Front 39

quality assurance programs

Back 39

programs that promote excellence in nursing.
-range from small programs to entire institutions, states, countries.
3 essential components of quality care:
1. structure
2. process
3. outcome

Front 40

quality-assurance programs: structure, process, oucome

Back 40

structure evaluation/audit: environment in which care is provided.
Process evaluation is nature and sequence of activities
Outcome evaluation focuses on measurable changes in health status of pt.

Front 41

quality improvement/continuous quality improvement CQI or total quality managment.

Back 41

-internally driven, focused on pt care, has no end points.
-outcome is improving quality rather than assuring quality.
-

Front 42

nursing audit

Back 42

method of evaluating nursing care that involves reviewing pt records to assess the outcomes of nursing care or the process by which these outcomes were achieved.