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ATI Fundamentals for Nursing (Nursing Process)
Ch. 7: Nursing Process
72
Nursing
09/07/2010

Additional Nursing Flashcards

 


 

Cards

Term
Steps in the Nursing Process
Definition

  1. Assessment
  2. diagnosis
  3. planning
  4. implementation
  5. evaluation
(ADPIE)

Term
Use of the nursing process results in...
Definition
A comprehensive, individualized, client-centered plan of nursing care that can be delivered in a timely, reasonable manner
Term
NANDA
Definition

 

  • (North American Nursing Diagnosis Association)
  • developed a standardized terminology for identifying client problems (nursing diagnosis)
  • A group of nursing  educators, theorists and advance practice nurses form US and Canada who develop standard terminology, content & format of nursing diagnoses
  • Group meets every 2 years to revise/update the list of approved nursing diagnoses; new diagnoses are tested to evaluate appropriateness and usefulness

 

Term
NOC and NIC
Definition

 

  • Created by Center for Nursing Classification and Clinical Effectiveness at University of Iowa
  • NOC: standardized terminology for nursing outcomes (Nursing Outcomes Classification [NOC]); describes general expected outcomes responsive to nursing interventions
  • NIC: for nursing interventions (Nursing Interventions Classification [NIC]) 

 

Term
Subjective data
Definition

  • Symptoms
  • usually obtained during a nursing history
  • include client's own feelings, perceptions and descriptions of their health status
  • Described verified and apparent only to the client

Term
Objective data
Definition

  • Signs
  • usually obtained during a physical examination
  • observable and measurable
  • felt, seen, heard, or smelled by the nurse

Term

Primary Sources of Data

(Subjective)

Definition

What the client tells the nurse:

"my shoulder is really, really sore"

Term

Primary sources of Data

(objective)

Definition

Data the nurse obtains through observation and examination:

the client is observed grimacing when attempting to brush her hair w/ her left arm

Term

Secondary sources of Data

(Subjective)

Definition

what others tell the nurse based on what the client has told them:

"she told me that her shoulder is sore every morning"

Term

Secondary sources of Data

(objective)

Definition

Data collected from other sources (e.g. family, friends, carefibers, health care professionals, literature review, medical records):

PT note in chart indicates that the client has decreased ROM of shoulder

Term
Definition
Term
Assessment/ Data Collection
Definition

  • Collected during initial assessmnet (baseline data), focused assessment, and ongoing assessment
  • Methods: observation, interviewing, physical exam, collaboration
  • subjective data
  • objective data

Term
Analysis requires the nurse to look at the data and...
Definition

  • recognize patterns or trends
  • compare the data w/ normal standards
  • arrive at diagnostic conclusions

Term

Nursing Dx

(define)

Definition
specifically describes the client's actual or potential reaction to a health problem that the nurse is licensed and skilled to treat
Term

Nursing Dx

("formula")

Definition

used to construct a nursing Dx

 

Problem statement r/t (related to) etiology AEB (as evidenced by) defining characteristics

Term
syndrome nursing Dx
Definition

signifies a problem that has common signs and symptoms that almost always present together

 

(used when a cluster of nursing Dx are often seen together [ex.  Rape-trauma syndrome related to anxiety about potential health problems and as manifested by anger, genitourinary discomfort, and sleep pattern disturbance.])

Term
wellness Dx
Definition
signifies a state of a client/family/community ready for improved health status
Term
Planning
Definition
the nurse sets priorities, determines client outcomes, and selects specific nursing interventions
Term

 

  1. goal
  2. client outcomes

 

Definition

 

  1. will identify the desired client status
  2. will identify the observable criterion that will determine success or failure of the goal

 

 

Term
the goal/client outcome must be...
Definition

 

  1. client-centered
  2. singular
  3. observable
  4. measurable
  5. time-limited
  6. mutually agreed upon
  7. reasonable

 

Term
Nursing Interventions
Definition

 

  • any treatment or action that the nurse performs to enhance/achieve the client's oucomes

 

Term
Definition
Term
each Nursing outcomes classification (NOC) includes
Definition
a definition, measurement scale and indicators
Term
each Nursing Intervention Classification (NIC) includes
Definition
a label (name), definition and a list of activities and rationales
Term

Types of interventions

(Nurse initiated/ independent interventions)

Definition

  • expected to benefit the client, based on scientific rationale
  • initiated by the nurse based on the client's nursing Dx, health care needs, and w/i the nurse's scope of practice
  • ex. turning the client every 2 hours to prevent skin breakdown

Term

types of nursing interventions

(physician initiated/ dependent interventions)

Definition

nuse initiates as a result of a primary care provider's order or facility/ agency protocol

 

(ex. blood administration procedure)

Term

types of nursing interventions

(collaborative interventions)

Definition

interventions the nurse carries out in collaboration w/ other HC team professionals

 

(ex. assuring client receives and eats his evening snack)

Term
NCP
Definition

Nursing Care Plan

end product of the planning step

allows for quick identification of pt nursing Dx, outcomes, & interventions that need to be implimented

Term

Implementation

(skills used)

Definition

1. intellectual skills (problem solving, creative and critical thinking)

2. interpersonal skills (therapeutic communication)

3. technical skills (psychomotor performance)

Term
Evaluation
Definition

nurse determines the effectiveness of the nursing care plan

the nurse will compare what actually happened to the desired client outcome

Term
Evaluation Questions
Definition

"were the desired client outcomes met?"

"were the nursing interventions appropriate/ effective?"

"do the outcomes and/or interventions need to be modified?"

Term
Factors that can lead to lack of goal achievement
Definition

incomplete database

unrealistic client outcomes

nonspecific nursing interventions

inadequate time for client to achieve outcome

Term

Problem Statement

(Nursing Dx)

Definition

  • Standardized terminology created by NANDA
  • brief phrase or term describing the client's response to actual or potential health problems
  • directs the development of desired client outcomes
  • descriptors or modifiers limiting or definig the diagnostic label

Term

Etiology

(Nursing Dx)

Definition

  • one or more probable causes of the health problem
  • factors causing or contributing to the health problem
  • related or risk factors of the health problem
  • biological, psychological, social, developmental, treatment-related and situational factors contributing to the cause of the problem

Term

Defining Characteristics

(Nursing Dx)

Definition

  • Subjective and objective data obtained from client assessment
  • cues and inferences that point to the existence of a particular diagnostic label

Term
Etiology should be manageable by 
Definition
nursing interventions
Term
Definition
Term

Q: subjective or objective data?

 

R: 22 bpm that is even and unlabored

Definition
Objective
Term

Q: subjective or objective data?

 

"I can only walk 3 blocks before my legs start to hurt"

Definition
Subjective
Term

 

Q: subjective or objective data?

 

pain rated at 3 on a scale of 1 to 10

 

Definition
subjective
Term

 

Q: subjective or objective data?

 

skin pink, arm, and dry

 

Definition
objective
Term

 

Q: subjective or objective data?

 

urine output of 300 mL/ 8hr

 

Definition
objective
Term

Q: subjective or objective data?

 

"my wife doesn't come to visit very often"

Definition
subjective
Term

Q: subjective or objective data?

 

dressing clean, dry and intact

Definition
objective
Term

Q: By the second postop day a client has not achieved satisfactory pain relief.  Based on this eval. what should the nurse do next based on the nursing process?

 

a. reassess the client to determine the reason satisfactory pain relief has not been achieved

b. wait to see if pain lessens over next 24 hours

c. change plan to ensure that client achieves adequate pain relief

d. teach client about the plan of care that is being implemented to manage his pain

Definition
A
Term

Q: when a nurse evaluated the care he has given a client, the client's responses to care are comparred with the

 

A. assessment data

B. nursing Dx

C. client outcomes

D. medical Dx

Definition
C
Term

Q: the cues and inferences that the nurse uses to choose a nursing Dx label are considered the 

 

A. probable cause

B. defining characteristics

C. nursing interventions

D. goals

 

Definition
B
Term

Q: in evaluation, the nurs must gather info about the client to

 

A. judge whether or not the client outcomes have been met

B. organize resources to proceed w/ implementing interventions

C. est. client-centered outcomes that are measurable and realistic

D. determine the priority nursing Dx and appropriate interventions

Definition
A
Term

Determine the correct nursing process step for the following statement:

 

"identify the client's health problem"

Definition
Diagnosis
Term

Determine the correct nursing process step for the following statement:


"call the social worker to visit the client for discharge needs"

Definition
implement 
Term

Determine the correct nursing process step for the following statement:


"develop a care plan"

Definition
Planning
Term

Determine the correct nursing process step for the following statement:


"client has crackles in the left lower lobes"

Definition
assessment (objective data)
Term

Determine the correct nursing process step for the following statement:


"develop a therapeutic relationship"

Definition
assessment
Term

Determine the correct nursing process step for the following statement:


"activity intolerance is related to prolonged immobility"

Definition
diagnosis
Term

Determine the correct nursing process step for the following statement:


"client will walk to the bathroom twice daily"

Definition
planning
Term

Determine the correct nursing process step for the following statement:


"client states, "I don't sleep well at night.""

Definition

assessment

(subjective data)

Term

Determine the correct nursing process step for the following statement:


"place all supplies for dressing change at bedside"

Definition
Implementation
Term

Determine the correct nursing process step for the following statement:


"bathe the client in the evening"

Definition
plan
Term

Determine the correct nursing process step for the following statement:


"nurse interprets data"

Definition
Diagnosis
Term

Determine the correct nursing process step for the following statement:


"client has active bowel sounds and is tolerating clear liquids well"

Definition
evaluation
Term

Determine the correct nursing process step for the following statement:


"expected outcomes are to be met w/i the first week"

Definition
plan
Term

Determine the correct nursing process step for the following statement:


"turn the client every 2 hr for first 24 hrs"

Definition
plan
Term

Determine the correct nursing process step for the following statement:


"transfer the client w/ the help of three staff members"

Definition
plan
Term

Determine the correct nursing process step for the following statement:


"client is unable to walk to the bathroom this morning"

Definition
evaluation
Term

Actual Nursing Dx

(rules for writing)

Definition

PRN

 

P=problem from NANDA list

R=related factors (NOT a medical Dx)

S=signs & symptoms (defining characteristics)

 

**Incorporating a medical Dx into a nursing Dx statement: secondary to the r/t portion

ex. diarrhea r/t GI disorder secondary to UC aeb watery bowel movements 5 times per day, abdominal distension, cramping w/ defication**

Term

Risk Nursing Dx

(rules for writing)

 

Definition

PR

 

P=problem (NANDA)

R=related risk factors

 

risk impaired skin integrety r/t obesity, excessive diaphoresis, confinment to bed

Term

Step #3: Planning

(4 Key steps)

Definition

1. Establishing priorities

2.Establishing outcomes

3. Determine interventions

4. Writing plan of care (POC)

Term
High Risk Nursing Dx
Definition

 

Impaired gas exchange
Decreased cardiac output
Ineffective thermoregulation
Ineffective airway clearance
Ineffective tissue perfusion
Risk for infection
Risk for injury
-Risk for suicide

 

Term
Intermediate Risk Nursing Dx
Definition

 

Impaired skin integrity
Impaired physical mobility
Urinary retention
Imbalanced nutrition
Acute pain
Anxiety
Self-care deficit

 

Term
Low Priority Nursing Dx
Definition

 

Decisional conflict
Interrupted family processes
Deficient diversional activity
Risk for impaired parenting
Impaired home maintenance
Impaired adjustment
Ineffective role performance

 

Term

Establishing outcomes:

(3 parts to a patient outcome)

Definition

1. problem- reverse statement of the problem in the PES/PR statement

2. expected outcome- what will be observed in patient after care is done to show the benefits of nurse care

3. target time- when pt is expected to be able to meet the outcome

 

ex. Nsg. Dx:

  Impaired physical mobility R/T musculoskeletal impairment AEB pain on ambulation, limited ROM, postural instability.

 

  Goal:

  Mr. J will demonstrate an improvement in physical mobility AEB ambulating 20 feet TID by 05-05-05.

Term
Nursing Intervention Guidelines
Definition

  • MUST be directed at altering the cause or related factors of the problem
  • MUST aide in achieving pt oucomes
  • MUST be safe for the pt
  • MUST be individualized and compatible w/ the patient's goals and values
  • MUST be based on Scientific Rationale
  • MUST be congruent w/ other therapies
  • MUST be ralistic for patient, hospital staff, and available rescources ($$)
  • creates opportunity for teaching by the nurse explaining the rationale for the intervention