The Nursing Process Flashcards Preview

Nursing 1012 Midterm > The Nursing Process > Flashcards

Flashcards in The Nursing Process Deck (22)
Loading flashcards...
1
Q

adpie

A
  • assessment
  • diagnosis
  • planning
  • implementation
  • evaluation
2
Q

assessment data collection

A
  • tests to see results
  • objective: vitals, diagnostic test results, facts, numbers
  • subjective: pain, what client is telling you, their feelings, what family sees
3
Q

assessment sources of data

A
  • primary: client
  • secondary: family, care taker, their chart
  • tertiary: journal articles, nurses past experiences
  • primary and secondary are directly related to client and tertiary is more general data
4
Q

nursing diagnosis vs medical diagnosis

A

nursing: persons response to a condition, clinical judgement, wellness promotion or potential risks, may change, shows our autonomy
- medical: the condition and causes, remains same

5
Q

steps in nursing diagnosis

A

1) identification
2) identify related factors
3) provide evidence to support diagnosis

6
Q

identification

A
  • identify focus that nursing diagnosis will address by looking at patterns in data that has been collected
  • focus on experience of client and this around them
  • likely to have more than one diagnosis
  • verify diagnosis with client
7
Q

identify related factors

A
  • figure out why the client is having specific problem

- medical diagnosis can be of assistance

8
Q

provide evidence to support diagnosis

A
  • summarize data in AEB statement

- justifying why they have diagnosis

9
Q

3 types of nursing diagnosis

A
  • actual
  • wellness or health promotion
  • risk
    focusing on entire person not just diagnosis
10
Q

actual

A
  • as issue for the client at the moment
11
Q

wellness or health promotion

A

readiness for enhanced education

12
Q

risk

A

things they are at risk for due to symptoms

13
Q

why is standardized nursing language important

A
  • improved communication among nurses and other professionals
  • increase visibility of nursing interventions
  • improved patient care
14
Q

North American Nursing Diagnosis Association

A
  • NANDA
  • creates language to identify clients or communities responses to situations
  • works closely with NIC and NOC
15
Q

Nursing intervention Classification

A
  • NIC

- what we are going to do

16
Q

Nursing Outcome Classification

A
  • NOC

- what we hope to see

17
Q

International Classification for Nursing Practice

A
  • ICNP
  • nursing diagnosis classification system supported by WHO
  • language similar to NANDA
  • more used for electronic records and documentation
  • linked with committee for international nursing language
  • includes outcome statements
18
Q

planning

A
  • goals: resolution of the area of concern or achievement of the goal
  • both short and long term (immediate vs future)
  • outcomes: specific, measurable and patient specific. how goal will be measured, what we will see in client
19
Q

Goals should be…

A
  • specific
  • measurable or meaningful
  • attainable or action-oriented
  • realistic of results-oriented
  • timely or time-oriented
  • start with “increase, decrease, improve, maintain, or stabilize”
20
Q

implementation

A
  • interventions: what we as nurses can to do address the areas of concern or to support wellness
21
Q

evaluation

A
  • reassess or evaluate to see if desired outcomes have been met
22
Q

goals vs objectives

A
  • both measurable
  • goals: broad
  • outcomes: measurable piece of a goal
  • ex: goal- decreased work of breathing
    objective- respiratory rate between 16 and 20