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The.Nursing.Process*
vocabulary words and notes
| Question | Answer |
|---|---|
| Nursing Process | systematic method in which the nurse & client work together to plan & carry out effective nursing care |
| Trial & error problem solving | experimental approach that tests ideas to decide which methods work & which methods don't work |
| scientific problem solving | precise method of investigating problems & arriving at solutions |
| critical thinking | process of objective reasoning; analyzing facts to reach a valid conclusion |
| nursing care plan-ncp | written list of the client's problems, goals & nursing orders for client care; guidelines used by healthcare facilities to plan the care for clients |
| what are the steps in the nursing process? | nursing assessment, nursing diagnosis, planning, implementation, evaluation |
| prioritization, prioritizing | following specific steps to determine the client's most important needs |
| client oriented | focused on meeting individualized needs |
| goal oriented | establishment of objectives or specific desired outcomes early in the nursing process |
| what is the method used to identify & treat client care problems? | nursing process |
| nursing assessment | systematic & continuous collection of data; analysis of information about the client |
| potential needs | needs which may occur; identified as at risk for... |
| objective data | facts that are observable & measurable |
| subjective data | information that only the client feels & can describe; what client tells you |
| observation | assessment tool that relies on use of 5 senses to discover information abot the client |
| what 3 methods are used to collect data? | observaton, interview, physical assessment(examination) |
| health interview or nursing history | way of soliciting information from the client |
| admission interview | if the interview is conducted when a client is admitted to a healthcare facility |
| medical history | if the interview is obtained by the physician |
| the purpose of a health history(interview) is... | to enable the nursing staff to plan effective & personalized care that will meet clients individual needs |
| nursing progress notes, also called nurses notes | documentation by nurses of care given & observations made |
| data analysis | analyzing each piece of information to determine its relevance to a client's health problems & its relationship to other pieces of information |
| assessment | systematic collection of information |
| signs | objective data-information that is observable & measurable |
| symptoms | subjective data-information that the client can only identify |
| what are the types of assessments? | database assessment, focus assessment, functional assessment |
| database assessment | initial information about the client's physical, emotional, social, & spiritual health |
| focus assessment | information that provides more details about specific problems |
| functional assessment | determining a person's ability to perform self care task |
| when does the nursing process begin to be utilized? | as soon as you enter a nurse-client relationship |
| nursing diagnosis | health problem that can be prevented, reduced, or resolved through independent nursing actions |
| medical diagnosis | statement formulated by a primary healthcare provider that identifies the disease a person is believed to have |
| prognosis | projected client outcome |
| what are the parts to a nursing diagnostic statement? | problem-NANDA etiology-cause signs/symptoms |
| which type nursing diagnosis don't include the third part of the diagnostic statement? | risk diagnosis & possible diagnosis |
| collaborative problems | problem in which nurses work with physicians or other healthcare providers |
| by what medical abbreviation are collaborative problems identified on a client's paln of care | PC-potential complication |
| diagnosis | identification of health related problems; recognition of a disease by its signs & symptoms made by a physician |
| what are the 5 categories of nursing diagnosis? | actual, risk, possible, syndrome, wellness |
| actual diagnosis | problem that currently exist |
| risk diagnosis | problem a client is at risk for developing |
| possible diagnosis | problem that may be present but requires more data collection to rule out or confirm its existance |
| syndrome diagnosis | cluster of problems that is present due to an event or situation |
| wellness diagnosis | situation in which a healthy person obtains nursing assistance to maintain his/her health |
| planning | process of prioritizing nursing diagnosis & collaborative problems, identifying measurable goals or outcomes, selecting appropriate interventions & documenting the plan for care |
| expected outcome | measureable behavior that indicates whether a person has achieved the expected benefit of nursing care |
| goal | expected or desired outcome |
| short term goal(objective) | outcomes that can be met in hours, few days to a week |
| long term goals(objectives) | outcomes that can take weeks or months to accomplish |
| nursing orders | directions for a client's nursing care |
| standards for care | policies that ensre quality client care |
| nursing interventions/nursing orders/nursing actions | activities that will most likely produce the desired outcomes |
| kardex | quick reference for current information about the client & the clients care |
| what are the characteristics of an expected outcome or goal? | client centered, specific, reasonable, measurable |
| what is a formal guideline for directing the nursing staff to provide client care? | nursing care plan |
| what is maslows hiearchy of needs in order? | 1. physiologic 2. safety 3. love 4. esteem 5. self actualization |
| implementation | to carry out a plan of care |
| dependent nursing actions | actions that nurses must follow explicitly according to physicians orders |
| interdependent nursing actions | actions that occur in cooperations with physicians & other team members |
| independent nursing actions | nursing actions that don't require a physicians order |
| accountability | responsibility for all actions that one performs |
| intellectual skills | knowing & understanding essential information |
| interpersonal skills | believing,behaving, & relating |
| technical skills | skills used to perform interventions |
| evaluation | process of determining whether a goal has been reached; measure the effectiveness |
| discharge planning | process in which a client is prepared for continued care after discharge from a healthcare facility |
| concept mapping | organizing information in a graphic or pictorial form |
| type of assessment that is repeated each shift or more often, takes about 15 minutes, is a collection of physical assessments, consists of unstructured questions, & rules out & confirms problems | focus assessment |
| type of assessment that is obtained on admission, performed once, suggest possible problems, and is time consuming | database assessment |
| type of assessment that has to be completed within the first 14 days of admission, is repeated at least every 12 months if no significant change, & identifies physical, psychological or social factors that affect self care | functional assessment |
| following is examples of what type data: weight, temperature, skin color, blood cell count, vomiting, bleeding | objective data |
| following are examples of what type data: pain, nausea, depression, fatigue, anxiety, loneliness | subjective data |
| the following nursing diagnosis identifies which Maslows need: imbalanced nutrition; less than body requirements | physiologic |
| the following nursing diagnosis identifies which Maslows need: Risk for injury | safety & security |
| the following nursing diagnosis identifies which Maslows need: ineffective breathing pattern | physiologic |
| medical records | written collection of information about a person's health problems, care provided & progress of client |
| recording | process of uniting information |
| documenting or charting | process of entering information |
| chart | binder or folder that enables the orderly, collection, storage, & safekeeping of a clients medical record |
| quality assurance, continuous quality improvement, total quality improvement | process of promoting care that reflects established agency standards |
| auditors | inspectors who examine client records |
| what are the types of client records? | source oriented records & problem oriented records |
| problem oriented medical record | records organized according to client's health problems in which heatlhcare team works collaboratively to identify priority problems |
| source oriented medical record | records organized according to the source of information |
| what type of record contains separate forms for physicians, nurses, dietitians, physical therapist, etc to make entries about specific client care? | source oriented medical record |
| what are the components of a problem oriented medical record? | data base, problem list, plan of care, progress notes |
| health record | manual or electronic account of a client's relationship with a healthcare facility |
| computerized charting | documenting client information electronically |
| electronic medical record | rapid form of documentation in healthcare facilities using various, individualized, computerized formats |
| manual health record | a collection of various forms & documents |
| medication administration record | list of all medicatios that the physician has ordered for a client; agency form used to document drug administration |
| what are the methods of charting? | narrative, SOAP, focus, PIE, charting by exception |
| narrative charting | chronological order; type of nurses' notes in which nurse documents what is occurring throughout the day |
| which method of charting, resembles a log or journal? | narrative charting |
| type of charting that is more likely to be found in a problme oriented medical record? | SOAP charting |
| charting method that demonstrates interdisciplinary cooperation with all healthcare personnel, making entries in same location on chart? | SOAP charting |
| focus charting | charting that focuses on a specific problem |
| PIE charting | charting which involves numbering problems & documenting assessments on a separate form |
| charting by exception | documentation in which only abnormal assessment findings or care that deviates from the standard is charted |
| progress notes | form nurses fill out at regular intervals to summarize a client's condition or response to treatment |
| case management | providing high quality care while effectively using healthcare resources & controlling cost |
| minimum disclosure | portions of isolated pieces of information necessary for an immediate purpose |
| beneficial disclosure | an exemption whereby an agency can release private health information without a client's prior authorization |
| how should an error be corrected in documentation? | cross out incorrect statement with single line enclose it in parentheses write error & initial it |
| what are some guidelines to remember when documenting? | document what you see, observe be specific when documenting use direct quotations for subjective data be prompt be clear, consistent |
| should assessments be documented subjectively or objectively ? | objectively |
| how should the chart be signed? | first initial, full last name, title or full first, last name, title |
| what should you do if you have a vacant line when charting? | draw line through the vacant line |
| traditional time | time based on 2-12 hour revolutions on a clock |
| military time | time based on a 24 hour clock |
| checklist | form of documentation in which nurse indicates with a check mark or initials that routine care has been performed |
| flow sheet | form of documentation that contains sections for recording frequently repeated assessment data |
| graphic flow sheets | graph, form, or picture that records large amounts of information collected at intervals over a specified period of time |
| change of shift reporting | means of exchanging information between ongoing & incoming staff on each shift |
| walking rounds | caregivers that move from client to client discussing pertinent information |
| rounds | visits to clients on an individual basis or as a group |
| what are some things to tell nurse during change of shift report? | name, age, room number, code status, diagnosis on admission, primary healthcare provider, lab test, scheduled test, surgeries, procedures, diagnostic studies, vital signs, iv site, fluid, rate, pain level, what relieves pain, activity level, diet, meds |
| what content may the fact sheet provide? | clients name, date of birth, address, phone number, religion, insurer, admitting physician, admitting diagnosis, emergency contact & number |
| what type of form provides instructions about the client's choices for care if they become unable to make decisions later? | advance directive |
| what type of form contains physicians review of client's current & past health problems, results of body system exam, medical diagnosis, or tenative plan for treatment? | history & physical examination |
| what form identifies lab & diagnostic test, diet, activity, meds, IV fluids, & clinical procedures? | physicians orders |
| what type form describes clients ongoing status & responses to current plan of care & potential modifications in plan? | physicians or multidisciplinary progress notes |
| which form documents information concerning the client's health patterns & initial physical assessment findings? | nursing admission database |
| what type form identifies client problems, goals, & directions for care based on an analysis of collected data? | nursing or multidisciplinary plan of care |
| what does the graphic sheet form convey information about? | trends in vital signs, weight, I & O, |
| what type form indicates focused physical assessment findings by individual nurses during each 24 hour period & routine care provided? | daily nursing assessment & flow sheet |
| what information does the Nursing Notes form provide? | narrative details of subjective & objective data, nursing actions, response of client, outcomes of communication with other healthcare personnel or client's family |
| what information is obtained on the Medication Administration record form? | drug name, date, time, route, frequency, name of nurse administering medication |
| what form contains the results of tests in a sequential order? | laboratory & diagnostic reports |
| what form identifies content that was taught, evidence of client's learning & need for repitition of reinforcement? | teaching summary |
| admission | entering a health care agency for nursing care & medical or surgical treatment |
| orientation | helping a person to become familiar with a new environment |
| discharge | termination of care from a health care agency |
| transfer | moving a client from place to place; discharging a client from one unit or agency & immediately admitting them to another agency |
| referral | process of sending someone to another person or agency for special services |
| stepdown units, progressive care units, transitional care units | units for clients who were once in critical condition but have recovered sufficiently to require less intensive nursing care |
| transfer summary | written review of the client's previous care |
| clinical resume | summary of previous care |
| extended care facility | healthcare agency that provides long term care |
| skilled nursing facility | nursing home that provides 24 hour nursing care under direction of a RN |
| intermedicate care facility | agency that provides health related care & services to people who require institutional care but not 24 hour nursing care because of mental of physical condition |
| basic care facility | agency that provides extended custodial care |
| continuity of care | uninterrupted client care despite the change in caregivers |
| home health care | in home healthcare provided by an employee of a homehealth agency |
| double charting | repititious entry of same information in the medical record |
| NCP | nursing care plan |
| UAP | unlicensed assistive personnel |
| ADL | activities of daily living |
| CC | client complaint |
| NANDA(I) | north american nursing diagnosis association(international) |
| AEB | as evidenced by |
| R/T | related to |
| POMR | problem oriented medical record |
| MIS | management information systems/services |
| EMR | electronic medical record |
| MAR | medication administration record |
| RAP | resident assessment protocol |
| MDS | minimum data set |
| CBE | charting by exception |
| SOAP | subjective, objective, assessment, plan |
| SOAPIER | subjective, objective, assessment, plan, implement, evaluation, response |
| PIE | plan, intervention, evaluation |
| APIE | assessment, plan, implementation/intervention, evaluation |
| DAPE | data, assessment, plan, evaluation |
| DARE | data, action, response, education |
| DARP | data, assessment, response, plan |
| RIE | recorded in error |
Created by:
1115060100
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