The Nursing Process - (Basics In Nursing)

Front 1

(def)

a systematic rational method of planning and providing nursing care

Back 1

Nursing Process

Front 2

(def)

the process of collecting, organizing, validating, and recording data (information) about a client's health status

Back 2

Assessing

Front 3

(def)

information (data) that is detectable by an observer or can be tested against and accepted standard; can be seen, heard, felt, or smelled

Back 3

objective data

Front 4

(def)

data that are apparent only to the person affected; can be described or verified by only that person

Back 4

subjective data

Front 5

(def)

the nurse's clinical judgment about individual, family, or community responses to actual or potential health problems/life process to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable

Back 5

Nursing diagnosis

Front 6

What are the 5 phases of the nursing process?

Back 6

- assessing
- diagnosing
- planning
- implementing
- evaluating

Front 7

an ongoing process that involves (a) assessing a situation (b) establishing goals and objectives based on assessment of a situation or future trends (c) developing a plan of action that identifies priorities, delegates who is responsible, determines deadlines, and describes how the intended outcome is to be achieved and evaluated

Back 7

Planning

Front 8

(def)

the phase of the nursing process in which the nursing care plan is put into action

Back 8

Implementing

Front 9

(def)

a planned, ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes

Back 9

Evaluating

Front 10

(def)

the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data

Back 10

Validation

Front 11

You observe that a patient's arm is red and tender at the IV site, and determine that it is infected and the IV will need to be relocated. What phase(s) of the nursing process were used in this case?

Back 11

assessing, diagnosing, and planning

Front 12

(def)

a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows

Back 12

Concept map

Front 13

(def)

a collegial working relationship with another health care provider in the provision of client care

Back 13

Collaboration

Front 14

Nurses frequently use what reference point when setting nursing diagnosis' priorities?

Back 14

Maslow's hierarchy of needs

Front 15

The nursing process is required by _______ ________ __________.

Back 15

National Practice Standards

Front 16

In 1859, who started the movement where a nurse was said to be in charge of someone's personal health?

Back 16

Florance Nightingale

Front 17

In 1955, who was first to use the name "nursing process"?

Back 17

Hall

Front 18

In 1961, who began assisting the individual whether they were sick or well?

Back 18

Henderson

Front 19

In 1967, who authored the text call "The Nursing Process"? How many steps were in the process at that time?

Back 19

Yura & Walsh (4 steps at that time)

Front 20

In 1974, who included an additional step in the nursing process, making it the 5 step process that we use today?

Back 20

Gabbie & Lavin

Front 21

What organization publishes a list of nursing diagnoses? How often is it published?

Back 21

NANDA - every 2 years

Front 22

What are 7 characteristics of the nursing process?

Back 22

- individualized
- systematic
- dynamic
- interpersonal
- outcome oriented
- universally applicable
- problem-solving approach

Front 23

What are 3 types of data collected in the assessment phase of the nursing process?

Back 23

- objective
- subjective
- historical

Front 24

A client tells you that they feel nauseated. What type of data is this?

Back 24

subjective data (aka symptoms)

Front 25

You do a physical assessment on a client. What type of data is this?

Back 25

objective data (aka signs)

Front 26

A client tells you that they are allergic to penicillin. What type of data is this?

Back 26

historical data

Front 27

What is the primary source of data? What is an example of secondary source of data?

Back 27

The client is the primary source of data. A family member or neighbor would be a secondary source of data.

Front 28

Which phase of the nursing process?

Obtain a nursing health history

Back 28

Assessing

Front 29

Which phase of the nursing process?

Conduct a physical assessment

Back 29

Assessing

Front 30

Which phase of the nursing process?

Review Client records and review nursing literature

Back 30

Assessing

Front 31

Which phase of the nursing process?

Consult support persons and health professionals

Back 31

Assessing

Front 32

Which phase of the nursing process?

Update, organize, and validate data

Back 32

Assessing

Front 33

Which phase of the nursing process?

Compare data against standards

Back 33

Diagnosing

Front 34

Which phase of the nursing process?

Cluster or group data

Back 34

Diagnosing

Front 35

Which phase of the nursing process?

Identify gaps and inconsistencies

Back 35

Diagnosing

Front 36

Which phase of the nursing process?

Determine client's strengths, risks, diagnosis, and problems

Back 36

Diagnosing

Front 37

Which phase of the nursing process?

Set priorities and goals/outcomes in collaboration with client

Back 37

Planning

Front 38

Which phase of the nursing process?

Write goals/desired outcomes

Back 38

Planning

Front 39

Which phase of the nursing process?

Select and write nursing interventions and nursing care plan

Back 39

Planning

Front 40

Which phase of the nursing process?

Communicate care plan to relevant health care providers

Back 40

Planning

Front 41

Which phase of the nursing process?

Perform planned nursing interventions.

Back 41

Implementing

Front 42

Which phase of the nursing process?

Document care and client responses to care

Back 42

Implementing

Front 43

Which phase of the nursing process?

Give verbal reports as necessary

Back 43

Implementing

Front 44

Which phase of the nursing process?

Judge whether goals/outcomes have been achieved and modify or terminate care plan

Back 44

Evaluating

Front 45

Which phase of the nursing process?

Make decisions about problem status

Back 45

Evaluating

Front 46

Which phase of the nursing process?

Cluster data to categorize behaviors which reveals the problem

Back 46

Diagnosing

Front 47

During diagnosing, the ________ becomes the nursing diagnosis.

Back 47

problem

Front 48

Analyzing and synthesizing data occurs during the ________ phase.

Back 48

Diagnosing

Front 49

When planning you should write a ______ for each problem and an expected ________ for each defining characteristic.

Back 49

goal

outcome

Front 50

Should the goal be broad or specific? What about the outcome?

Back 50

The goal should be broad, and the expected outcome should be specific.

Front 51

(def)

broad statement reflecting resolution of the problem

Back 51

Goal

Front 52

(def)

specific, measurable statements that reflect resolution of the defining characteristics

Back 52

Expected Outcomes

Front 53

Is the following a goal or outcome?

"Ms. Reynolds' anxiety will decrease within 1 week AEB"

Back 53

Goal

Front 54

Is the following a goal or outcome?

"respiration rate between 12-20 per minute, with no SOB"

Back 54

Outcome

Front 55

Signs and symptoms are referred to as what?

Back 55

Defining characteristics

Front 56

What is the focus of a medical diagnosis?

Back 56

the illness

Front 57

What are the 2 primary purposes of writing goals/outcomes?

Back 57

- serves as criteria for evaluation of client progress
- provides direction for nursing interventions

Front 58

(def)

actions that the nurse takes to prevent, reduce or eliminate the problem or diagnostic label

Back 58

Nursing interventions

Front 59

Should a nursing intervention be general or specific?

Back 59

specific, it should tell who, what, when, where, and how often

Front 60

What are the 3 types of nursing interventions?

Back 60

- physician-initiated
- nurse-initiated
- collaborative

Front 61

What is a dependent order?

Back 61

a physician-initiated order