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Flashcards in Nursing Process Deck (108)
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Nursing Process Steps

A.D.P.I.E Assessment Nursing Diagnosis Planning Implementing Evaluation

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Assessment

deliberate & systematic collection of data about a patient 1. collection/verification of data 2. analysis of data purpose=to establish a database of patient information

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Nursing Diagnosis

clinical judgment about an individual, family or community responses to actual & potential health problems or life processes that the nurse is licensed & competent to treat *provides basis for selection of interventions

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Planning

setting priorities, identifying patient-centered goals/expected outcomes, and prescribing nursing interventions

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Implementation

performance of nursing interventions necessary for achieving goals/outcomes of nursing care

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Evaluation

deciding whether, after interventions, a patient's condition/well-being has improved

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Relationship between Nursing Process & Critical Thinking

use of the Nursing Process is required to make nursing care decisions through critical thinking critical thinking required to analyze thoughts, actions & knowledge in nursing process

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Health History

includes information about physical & developmental status, emotional health, resources, goals, values, lifestyle & expectations physical exam findings summary of lab results & diagnostic testing

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Interview

organized conversation with patient orientation phase, working phase, termination phase *patient is the best source of information

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Physical Exam

examining patient's body to determine state of health

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Observation

noticing patient behavior (verbal & nonverbal), patient function *adds depth to objective database

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Subjective Data

patient's verbal descriptions of problems

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Objective Data

observations & measurements of patient's health status

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Sign

quality notices by others besides the patient

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Symptom

quality reported by patient

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Open-Ended Questions

questions requiring more than 1-2 word answers prompt to describe situation, leads to conversation

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Close-Ended Questions

questions that limits answer to 1-2 words

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Back-Chanelling

giving positive comments during interview

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Data Validation

comparison of data with another source to confirm accuracy *often leads to gathering more information

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Components of Nursing Diagnosis

1. diagnostic label- NANDA approved diagnosis name (EX: fatigue) 2. related factor- reason patient is displaying diagnosis (EX: related to depression) 3. defining characteristic (EX: evidenced by lack of energy)

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Medical Diagnosis

identification of a disease condition based on an evaluation of physical signs, symptoms, history & diagnostic tests/ procedures *determined by physicians & advanced care nurses ONLY

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Collaborative Problems

actual or potential physiological complication that nurses monitor to detect onset of changes in patient status

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Cue

information obtained through use of senses

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Inference

judgment of cues

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Functional Health Patterns

theory/ practice standards that provide categories of information to assess

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Focused Assessment

focus on patient situation beginning with problematic areas then asking follow-up questions

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Data Cluster

set of signs & symptoms gathered during assessment grouped together logically

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Data Analysis

recognizing patterns/trends in clustered data by comparing them with standards & coming to a reasoned conclusion about patient response

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NANDA-I

North American Nursing Diagnosis Association organization for nursing diagnoses

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Defining Characteristics

clinical criteria or assessment finding that support an actual nursing diagnosis