Term
| FIVE COMPONENTS OF NURSING PROCESS |
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Definition
Assessment- data from history&physical
Nursing diagnosis-problem exp.sob,risk for falling
Planning-assess goal how to get to it
Implementation-doing procedure or plan
Evaluation- was goal achieved |
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Term
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Definition
| step by step process with observable results used to solve problems |
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Term
| Construction of a plan of care for the patient is made by? |
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Definition
is collaborative process among the nurse, the patient, and other health team members
ALWAYS fashioned to each patient all will be different |
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Term
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Definition
| means requiring careful judgment |
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Term
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Definition
| in this context, means to reason |
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Term
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Definition
is directed, purposeful, mental activity by which ideas are evaluated, plans are constructed and desired outcomes decides.
keep open mind and be unbiase and se priorities |
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Term
| what is a focused assessment? |
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Definition
| when patient has new complaint or problem you assess just what pertains to the problem |
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Term
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Definition
| can’t see patient tells you exp. headache |
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Term
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Definition
| can see this or measure this ( vitals, vomiting, weight, test results ) |
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Term
| what is interview focused on and the 3 stages |
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Definition
focused on gathering data not social interaction. Specific info on pt’s health
Stages 1) opening 2) body interview questions 3) closing anything else I didn’t ask |
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Term
| when is physical assessment done |
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Definition
| always apone admition and within the 1st hr of each shift. |
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Term
| what is done in physical assessment |
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Definition
| initial observation, head, vitals, heart/lungs,Abdomen, extremities, tubes and equipment, pain status. |
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Term
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Definition
| North American Nursing Diagnosis Association can only use these |
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Term
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Definition
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Term
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Definition
| what pt said and can not see |
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Term
| CONSTRUCTION OF NURSING DIAGNOSIS |
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Definition
| Problem + Etiology + signs and symtoms |
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Term
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Definition
| for basic survival take precedence |
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Term
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Definition
| goal pt will do or reach and then how the nurse will help reach |
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Term
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Definition
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Term
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Definition
| anything for longer than 10 days |
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Term
| how would you express a goal |
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Definition
| what is patient excepted to do (will do this by date) |
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Term
| DO NOT USE FOR TIME FRAME |
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Definition
| within 24 hrs. either at all times or specific date or time intravels time frame should be realistic. |
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Term
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Definition
| will always change do to new problems or eliveated problems |
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Term
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Definition
| Are intervention suppose to help the patient to reach their goals more efficiently and quickly and see potential problem and keep them from becoming a problem |
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Term
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Definition
| whereInterventions are preformed & carried out and responses to them are assessed |
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Term
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Definition
| can be done any time of day |
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Term
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Definition
| must be done at a set time |
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Term
| what do you need to make sure you have and check before implementing the assessment |
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Definition
Make sure you know time frame restrictions (visitors coming, tests being done, dr’s
Coming, medication distribution schedule)
Equipment and supplies are gathered |
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Term
| STANDARD STEPS FOR ALL NURSING PROCEDURE |
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Definition
STEP A: perform the task according to protocol
STEP B: check order, collect the equipment and supplies, and wash hands
STEP C: identify and prepare the patient
STEP D: provide privacy and institute safety precautions; arrange the supplies & equipment
Make sure equip. functioning ,safety, raise bed to working height, raise siderail,make
Sure wheels looked, wash hands
During procedure
STEP E: use standard precautions and aseptic techniques as appropriate
After procedure
STEP X: remove gloves and other protective equipment
STEP Y: restore unit, collect all equipment, clean room
STEP X: record and report procedure |
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Term
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Definition
PRIORITY- more important than something else at that time ( life threatening 1st)
Life threatening comes 1st
Medium priority threaten health or coping ability
Low priority- problems do not have major effect on the person if not attended to right away |
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Term
| CONTINUOUS QUALITY IMPROVEMENT (CQI) |
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Definition
| Continuous process of Identifying specific area’s that need changes by everyone Dr’s, nurses, hospital reps. Not to punish you . exp. teaching everything Could involve chart audit. Make sure standards of care me |
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Term
| STEPS CONSTRUCTION OF NURSING CARE PLAN |
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Definition
Collect date
Analyze to determine potential problems
Choose nursing DX
Rank nursing DX
Plan nursing care by defining goal
Nursing interventions to assist in outcomes
Implement the nursing intervention
Evaluate the actual outcomes |
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