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chapter 1 exam
Terms in this set (150)
Physical Assessment Techniques
Physical Assessment types
comprehensive, focused, & emergency
subjective and objective
Factual, related to reality or physical objects; not influenced by emotions, unbiased
1. signs, physical examination, lab results, test results
actual nursing diagnosis
describes human responses to health conditions or life processes
acute pain related to physical injury
1. complaint of pain @ a level 8 on a scale of 0 to 10
2. fracture on right femur
ineffective airway clearance
rhonchi in left lung
examples of health promotion diagnosis
1. readiness for enhanced immunization status
2. readiness for enhanced family practice
3. readiness for enhanced nutrition
these include independent and dependent nursing intervetions
written by physicians and list specific action to be taken by a nurse or other health care professionals
examples of standing orders for a patient with chest pain
1. assess VS
2. Obtain an ECG
3. initiate or maintain telemetry
4. initiate O2 therapy
systemic method of critical thinking used by professional nurses to develop individualized plans of care
who used the first nursing process
Five steps of the nursing process
the nursing process is
cyclic rather than linear
the nursing process is
analytical, dynamic, organized, collaborative, outcome oriented and adaptive
use critical thinking
changes over time depending on the patients needs
provides standardized method of addressing patient needs worldwide
What does assessment include?
data collection: primary, secondary, subjective, objective
symptoms and health history
clear related data
identify nursing diagnosis
list supporting data
what does the list of supporting data include
etiology, signs, symptoms
1. prioritize nursing diagnosis
2. personalize care plans
what does the interventions include
continues, discontinue, revise, adapt
Nursing Interventions Classification (NIC)
first comprehensive, validated list of nursing interventions applicable to all settings that can be used by nurses in multiple specialties and facilitates the work of identifying appropriate interventions
what part of ADPIE does NIC fall under
to work together
the assesment step
data is gathered through observation, interviews, and physical assesment
data is analyzed, validated and clustered with related assessment findings
description of what the nurses observes and discovers
prioritizes and identifies STG and LTG
STG and LTG must be
realistic, measurable, patient focused
specific nursing interventions and treatments designed
when is specefic data collected
nurses asses the state of a patients physical, psychological, emotional, environmental, cultural, and spiritual
where does the assment come from
patient, family, community, health care professional
information collected for the specific purpose at hand
information that already exists somewhere, having been collected for another purpose or family members
age, gender, nutritional status, soceconomic status
examples of diagnosis
obesity, distubed body image, lack of knowledge, impared parenting, sleep deprivation, risk for infeciton
where is the NOC found
examples of planning
strong parenting skills, improved body image
labels for diseases
consider patients response to the disease and diagnose and life situations in addiction to making clinical judgements based on diagnosis
is the NANDA1 integrated in EMR
when does collaborative care come into play
weeks to months
Outcome Identification is in what
listing behaviors or observable items that indicate attainment of a goal
interventions can be
independent, dependent, or collaborative
written plan that details the nursing activities to be executed in specific situations
DO NOT REQUIRE physicians order
Evaluation is not
a record of care
Define the Nursing Process
scientific method through which professional nurses systemically identify and address actual or potential patient problems
allows nurses to collect essential patien data, articulate the specefic needs of individual patients and effectively communicate those needs, establish realistic goals
when where the 5 primary steps of the nursing process identified
when did planning outcome and identification come to the nursing process
what is the purpose of the nursing diagnosis
organize the way nurses think about patient care
what is the primary purpose of the nursing process
communicate patient needs
On what premise is a nursing diagnosis identified for a patient?
a. First impressions
b. Nursing intuition
c. Clustered data
d. Medical diagnoses
Methods of Assessment
1. Chris is planning care based on use of nursing theory in caring for Mr. Moats. Using nursing theory to define a phenomenon uses which of the following components? Select all that apply.
B. Nursing process
A theory is a set of:
concepts, definitions, assumptions, and propositions that define a phenomenon. The theory explains how these components are uniquely related in the phenomenon.
defines nursing as assisting the individual, sick or well, in the performance of activities that will contribute to health, recovery, or peaceful death that the individual would perform unaided if he or she had the necessary strength, will, or knowledge.
Nurses must use a strong scientific knowledge base. Erikson's Stages of Growth and Development is an interdisciplinary theory.
3. Chris reviews Erikson's Stages of Growth and Development to determine which state Mr. Moats is in. This is an example of what type of theory?
A. Interdisciplinary Theory
B. System Theory
C. Mid-Range Theory
D. Prescriptive Theory
Release of Information
what are the 3 phases of nursing interview
1. orientation 2. working 3. termination
the first phase of group interaction, in which members become adjusted to one another and to the group's task. ASK questions
Goals for care. This is the purpose for interaction. Active engaged listening is very important
2. educational needs are assessed
what should be conducted during the working phase
review of systems
at the end of interview to review key findings and prepare for conclusion of the decision
where do you find out demographic data
orientation phase of assessment
objective data on patient's condition during assessment
determine organ location and size
determine size shape and borders or ogan masses
sounds made by organs
health history and complete physical examination, usually conducted when a patient first enters a health care setting; provides a baseline for comparing later assessment
assessment conducted to assess a specific problem; focuses on pertinent history and body regions
at beginning of acute care when on shift
a physical examination done when time is a factor, treatment must begin immediately, or priorities for care need to be established in a few seconds or minutes
the medical screening of patients to determine their relative priority of need and the proper place of treatment
hint or an indication of a potential disease process or disorder
3 ways to organize data
head to toe
gordons functional health
Formulation of Nursing Diagnosis
facilitates clear communication of patient needs and promotes professional accountability and autonomy by defining and describing the independent area of nursing practice
n effective vehicle for communication among nurses and other health care professionals.
professional nurses are required to
Identify accurate, applicable nursing diagnoses to guide quality, individualized nursing care of patients.
• Consider ethical and legal consequences for failure to identify areas of concern requiring treatment.
• Understand the implications of delayed recovery, further negative health issues, and, if it occurs, the death of the patient.
• Realize the ultimate risk for litigation involving the nurse if accurate nursing diagnoses are not identified.
• Formulate individualized nursing diagnostic statements at all levels of professional practice, and assign medical diagnoses within the scope of the nurse practice acts governing advanced practice nursing.
the nursing diagnosis is
a great way for healthcare providers to communicate
cause of disease
difference between assessment and diagnosis
Patient assessment data is clustered, a nursing diagnosis is identified, and supporting data is listed as part of the diagnosis step in the nursing process
difference between medical diagnosis and nursing
medical diagnoses identify and label medical (physical and psychological) illnesses
Nursing diagnoses consider a patient's situation more holistically, including how the patient is responding to current circumstances
Three types of nursing diagnostic statements written in NANDA1 format
problem-focused, risk, and health promotion
Problem-focused nursing diagnoses
clinical judgments about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community
risk nursing diagnosis
identify risk factors that are vulnerabilities of an individual, family, group, or community for developing negative human responses to health conditions or life processes
Health promotion nursing
clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential
what is the very frist label of every section of NANDA-1
concise term or phrase that represents a pattern of related, clustered data.
It describes the diagnostic focus and requires nursing judgment before its assignment to a patient
To accurately identify diagnosis labels for a patient, the nurse mus
(1) understand the meaning of a diagnostic label, (2) cluster and analyze related assessment findings, and (3) make a clinical judgment based on the patient's condition
the second part of a problem-focused nursing diagnosis consists of
underlying cause or etiology of a patient's problem.
what is written in the 3rd section of a problem-focused NANDA
cues or clusters of related assessment data that are signs, symptoms, or indications of a problem-focused, or health promotion nursing diagnosis.
rganizing patient assessment data into groupings with similar underlying causes
What is the primary difference between a NANDA-I risk nursing diagnosis and a problem-focused nursing diagnosis?
a. Related factors are not part of a risk diagnosis.
b. There is no cause and effect relationship established.
c. Defining characteristics are subjective in a risk diagnosis.
d. There are no nursing interventions prescribed with a risk diagnosis.
PES stands for problem, etiology or related factor, and symptoms or defining characteristics.
how to begin planning
the nurse prioritizes each nursing diagnosis that is identified and establishes goals in collaboration with the patient.
who should be involved in planning process
nvolving patients in planning their care helps them
(1) be aware of identified needs, (2) accept realistic and measurable goals, and (3) embrace interventions to best achieve the mutually agreed-on goals.
(two or more medical conditions or disease processes occurring at the same time
what helps organize the most urgent needs to least
maslows hierarchy of needs
Maslow's Hierarchy of Needs
physiological, safety, love/belonging, esteem, self-actualization
airway, breathing, circulation
consider the patient's physical, mental, and spiritual condition in relation to the ability to attain goals.
written specifically for the patien
specific, with numeric parameters or other concrete methods of judging whether the goal was met.
When planing what are the 3 goals
realistic, measurable, patient-centered, time
Example of ICNP with supporting data
Temperature elevation of 102.4°F
Skin warm to touch
standardized vocabulary used for describing patient outcomes. In this system, an outcome is "an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing interventions"
NURSING OUTCOME CLASSIFICATION (NOC) AND INDICATOR
during the planning phase of the nursing process, the nurse works with the patient, family, and other caregivers to design activities that can assist the patient in improving health and attaining goals.
What are they
3 types if interventions
independent, dependent, and collaborative
mprehensive, research-based, standardized collection of interventions and associated activities. NIC provides nurses with multidisciplinary interventions linked to a nursing diagnosis and a corresponding NOC.
NURSING INTERVENTION CLASSIFICATION (NIC)
dependent nursing interventions
actions that require an order from a physician or another health care professional
examples of dependent interventions
oxygen administration, dietary requirements, medications, and diagnostic tests
Implemention phase includes
1. Interventions-dependent, independent, collaborative
2. Care-direct, indirect
4. Care plans-clinical pathway, protocol, standing order
consists of performing a task (e.g., repositioning a patient, assessing vital signs, administering medications, teaching patients and families, calling chaplains) and documentation of each intervention
Conciderations to take when making and intervention
Patient education and health literacy level
• Relevant cultural, religious, or ethic factors and limitations
• Potential communication or language barriers
• Patient abilities and condition status
focuses on the patient and the patient's response to nursing interventions and outcome or goal attainment.
interventions that are carried out by having personal contact with patients
example of direct care
cleaning an incision, administering an injection, ambulating with a patient, and completing patient teaching at the bedside
tasks that are undertaken on a regular basis: eating, dressing, bathing, toileting, and ambulation.
would a patient after knee surgery need short term or long term goals
individuals use professional guidance to address personal conflicts or emotional problems.
encourages patients to express their concerns.
Examples of direct care
Teaching, informal counseling, physical care, ADL. Reassessment
includes nursing interventions that are performed to benefit patients but do not involve face-to-face contact with patients
Examples of indirect care
giving change-of-shift report, communicating and collaborating with members of the interdisciplinary health care team, and ensuring availability of needed equipment.
supporting and working on behalf of patients or people for whom they have concern.
transfer of responsibility for performing a task to another person while the nurse who delegated the task remains accountable
5 rights of delegation
1. Right task
2. Right circumstance
3. Right person
4. Right direction/communication
5. Right supervision/evaluation
independent nursing interventions
asks within the nursing scope of practice that the nurse may undertake without a physician or PCP order
dependent nursing interventions
tasks the nurse undertakes that are within the nursing scope of practice but require the order of a primary care provider to be implemented.
sometimes referred to as care pathways, care maps, or critical pathways, are multidisciplinary resources designed to guide patient care. Clinical pathways emerged in the 1980s in an effort to provide better-quality, standardized care for patients, and they were developed through evidence-based practice research
written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order.
Some physician orders are received through a preapproved standardized
example of a standing order
hen patients return to their rooms after cardiac catheterization, standing orders may indicate that the patients are to remain on bed rest for a specified period
Collaborative nursing interventions
require consultation and coordination of patient care with a variety of members of the health care team
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