Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
34 Cards in this Set
- Front
- Back
6 Phases of the Nursing Diagnosis |
Assessment, Diagnosis, Outcomes, Planning, Implementation, and Evaluation |
|
Assessment |
-Gathers information about patients condition -Includes cues, subjective, and objective, primary and secondary |
|
Diagnosis |
Identifying appropriate nursing diagnosis from patients problems |
|
Outcomes |
Set goals of care and desired goals Identify appropriate actions to complete goals |
|
Planning |
Plans interventions that will will patient meet set goals or outcomes |
|
Implementation |
Implement proposed plan |
|
Evaluation |
Perform ongoing assessments allowing if proposed goals have been met |
|
Database |
large store bank of information of patient |
|
Nursing Diagnosises includes: |
Title or label, definition of title of label, contributing etiologic or related factors, and defining characteristics -Should be researched based |
|
Complete assessment includes: |
-Review and physical examination of all body systems
-Cognitive, psychosocial, emotional, cultural. and spiritual components |
|
Collaborative Nursing |
Health-related problems that nurse anticipates based on condition or diagnosis of patient. Both Health provider and nurse- prescribed interventions are used in management care |
|
Medical Diagnosis |
Health care provider only allowed to diagnose and treat. Identification of disease or condition with evaluation of physical signs, symptoms, patient interview, tests, procedures, medical records, and potential history. |
|
Patient-centered goals or outcomes |
Provides a description of specific, measurable behavior that patient will be able to exhibit in a time frame after interventions |
|
Evaluation steps: |
-Review patient goals -Reassess patient to gather information to indicate actual response to intervention -Compare actual outcome with desired outcome |
|
Conclusions of evaluation |
-Achieved -Not Achieved -Partially Achieved |
|
Clinical Pathways |
a multidisciplinary plan for clinical interventions |
|
Critical Thinking |
is reflective and reasonable thinking that is focused on deciding what to believe or do, its the art of thinking about your thinking while you are thinking
|
|
Evidence-based practice |
Systematic problem-solving practice that delivers high-quality care and best outcomes for individuals. |
|
Subjective Data |
-Information provided by patient. -Also called symptoms and subjective cues -Hidden until shared by patient |
|
Objective Data |
-Observable and measurable signs -Signs and objective cues |
|
Primary Source |
Patient considered accurate reporter |
|
Secondary Source |
Family, significant others, medical records |
|
Data Clustering |
Method of organization between related data which helps identify nursing diagnosis |
|
Syndrome Nursing |
Clinical judgement describing specific cluster of nursing diagnosis's that occur together and best addressed together and through similar interventions (PTSD, Risk of disease) |
|
Physician-prescribed Intervetions |
Actions ordered by physician for nurse or other health care professionals to perform. |
|
Nurse-prescribed Interventions |
Actions a nurse is legally able to order or begin independently (back massage, turn patient) |
|
Characteristics of Critical thinkers (6) |
-Question information, conclusions -Look beneath the surface -Logical and fair in thinking -Self-correction -Creative thinking -Analyze or critique behaviors |
|
Risk Nursing |
Clinical judgement that problem might develop |
|
Wellness Nursing |
Transition from specific well-being to higher level of well-being |
|
Maslow's Hierarchy of Needs
|
Place severe needs above all. Phsiologic needs, safety and security, love and belonging, self-esteem, self-actualization
|
|
Case Management |
Assignment of a health care provider to an individual patient |
|
Nursing Process |
A problem-solving method, systematic, goal-directed, flexible, rational approach, ensures consistent, continuous, quality nursing care, provides a basis for professional accountability, input of nurse and patient/ family critical |
|
Included in a nursing order
|
Date, signature of nurse responsible for the care plan, subject, action verb, qualifying details |
|
Variance |
Expected outcome was not reached |