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42 Cards in this Set

  • Front
  • Back
nursing process
-assess to determine need
-nursing diagnoses
-expected outcomes and plan of care
nursing process enables the nurse and pt to accomplish the following
-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
characteristics of nursing process
-outcome orientated
-universally applicable in nursing situations
trial-and-error problem solving
testing any number of solutions until one is found that works.
-not recommended for nursing practice
scientific problem solving
systematic, seven-step, problem solving.
2-data collection
4-plan of action
5-hypothesis testing
6-interpretation of results
blended skills (4)
-cognitive skills/critical thinking
-technically skilled nurses
-interperonsal skills
-ethical/legal skills
standards for critical thinking
-adequate for the purpose
concept mapping
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.
all the pertinent pt info collected by teh nurse and other healthcare professionals.
initial assessment
performed shortly after the pt is admitted.
purpose is to establish a complete database for problem identification and care planning.
focused assessment
data about a specific problem that has already been identified.
emergency assessment
when a physiologic or psychological crisis presents.
identify life-threatening problems.
time-lapsed assessment
scheduled to compare a pt's current status to baseline data obtained earlier.
minimum data set
specifies the info that must be collected from every pt.
nursing assessment guides are based on holistic models rather than medical models.
characteristics of data
-factual and accurate
nursing history
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
components of nursing history
-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
-developmental history, family hisotry
-educational needs
Interview-four phases
1. preparatory; nurse prepares to meet pt.
2. introduction
3. working phase: gathers all the info for the subjective database.
4. termination
nursing physical assessment
objective data. normally follows the nursing history and interview.
subjective and objective data you identify
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
nursing types of problems
-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
data cluster
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.
no problem?
-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.
formulation of diagnosis (structure)
problem, etiology, defining characteristics.
actual nursing diagnosis
a problem that has been validated by the presence of major defining characteristics
risk nursing diagnosis
clinical judgments that an individual, family, community is more vulnerable to develop the problem than others.
possible nursing diagnosis
statements describing a suspected problem for which additional data are needed.
-potential, risk for impaired skin integrity.
-possible, possible chronic low self-esteem.
wellness diagnosis
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.
syndrome nursing diagnoses
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.
Maslow's hierarchy of human needs
1. physiologic
2. safety
3. love and belonging
4. self-esteem
5. self-actualization
guidelines for writing outcomes
-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
1st part of nursing diagnosis suggests what?
suggests pt goals/outcomes
2nd part of the nursing diagnosis suggests what
suggests nursing interventions
nurse-initiated interventions/independent nursing actions
nurse-prescribed interventions resulting from their assessment of pt needs.
written plans that detail the nursing activities to be executed in specific situations.
standing orders
empower the nurse to initiate actions that ordinarily require the order or supervision of a MD.
types of outcomes
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.
quality assurance programs
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
quality-assurance programs: structure, process, oucome
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.
quality improvement/continuous quality improvement CQI or total quality managment.
-internally driven, focused on pt care, has no end points.
-outcome is improving quality rather than assuring quality.
nursing audit
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.