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22 Cards in this Set
- Front
- Back
Nursing Process is ______ and _______ |
Dynamic and Continuous
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Using Critical Thinking in the Nursing Process
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-Recognizing an issue exists (patient problem)
-Analyzing information about the issue (data) -Using information (knowledge, experience, standards, attitudes) to evaluate the issue -Making a conclusion |
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Primary Source |
Patient |
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Secondary |
Family, physician, etc. |
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Subjective Data |
Patient Interview and Health History |
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Objective Data |
Physician Open ended questions -Physical Exam -Diagnostic and Lab Data |
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Skin is cool and damp, what type of data is this? |
Objective |
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Usually voids two times during the night, what type of data is this? |
Subjective |
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Analysis and Interpretation of Data Clustering |
Take all of the information given from patient and place them according to system (cardio, pulmonary, etc.) |
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Medical Diagnosis VS. Nursing Diagnosis |
Medical (Physician) treats the disease, nursing diagnosis deals with patients response to the disease. |
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NANDA |
North American Nursing Diagnosis Association |
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Collaborative Problem |
When nurses and doctors work together to prevent the disease process from occurring. Sometimes make protocols for specific medical diagnosis. |
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The nursing diagnostic process is ________ |
Decision making steps |
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Different types of nursing diagnosis |
Actual nursing diagnosis Risk nursing diagnosis Health promotion diagnosis - acknowledges a certain type of lifestyle or action that can cause future problems to patient or community such as not receiving a flu shot. |
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Nursing Process Format- PES |
Problem (NANDA)- Activity intolerance Etiology (related factor)- related to bed rest Symptom (defining characteristic)- patient reports fatigue and weakness |
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Types of Nursing Interventions |
Independent: Nurse-initiated interventions
Dependent: Physician-initiated interventions Interdependent: Collaborative interventions |
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Discharge Planning is planned _______ |
The day the patient is admitted. Any education needs? |
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Nursing Care Plan |
Plan made my head nurse of patient and carried out by all nurses who care for patient. |
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Nurses should never delegate _____? |
Assessment unless it is to another nurse |
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Nursing Process Evaluation |
To see if goals have been met. -Goals have been met. -Goals have been partially met. -Goals have not been met. |
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If goal has not been met? |
Start over with assessment and the care plan (thats why the process is continuous). |
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Critical Pathways |
Allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for patients.
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