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N212 TLO 3.3
Nursing PRocess
| Question | Answer |
|---|---|
| Definition of NP | Variation of scientific reasoning that allows nurse to organize nursing practive, |
| NP provides a common language for nurse to do what | think through clients clinical problems |
| this process allows nurses to modify what | care as needs pt change |
| what is the purpose of NP | DX and treat human responses to actual of potential problems |
| treating human responses is different from physician treatment how | nurses treat human responses, while physicians treat disease |
| what are the five phases of the nursing process | assessment, nursing diagnosis, planning, implementation and evaluation |
| why do nurses use critical thinkinng | to make informed desicians of the client |
| critical thinking: what are the components of it | knowledge base, nursing experience, critical thinking competencies, attitude, confidence, fairness, risk taking, curiosity, integrity, perseverance, creativity, |
| Criticatl thinking standards: what are the intelectual standards; the professional standards | logical, clear, accurate; ethics, responsibility |
| NP- Assessment: def; what is the purpose | collection of pt current and past health statuss on which to base care; to establish a database about client's perceived needs, health problems and responses to these problems |
| NP: Nursing diagnosis -Def; this is the 2nd part of what; in the ND you analyze what | is the act of identifying and labeling human responses to actual of potential problems/life processes; assessment; all assessment data; |
| NP: Planning- def; what are the goals; nurses identify what | goals are set; desired outcomes of the patient; appropriate nursing actions |
| NP: implementation/intervention- def; | the activation of the plan with the use of the nursing inteventions (perform the nursing actions identified in planning |
| NP: Evaluation- def; do we eval goals on interventions | determines if the pt goals have been met as a result of nursing inteventions; goals |
| NP Assessment- what are the 2 steps | collection and verification of data and analysis of data to develop ND and and individual plan of care |
| NP Assessment- what are the 2 types of data; def of subjective; def of objective; Data is measured based on what | subjective and objective; clients perception about their health problems; observation or measurements made by the datat collector; accepted standards (cm, Kg, etc) |
| NP Assessment- what are the sources of data; what are the 3 methods of data collection; | pt, fam, sig. other, health care team , records, lit review, experience; interview, physical exam, diagnostic tests |
| NP Assessment- NP Assessment- what is obtained in the interview; what type of physical exam; | health history; head to toe exam and IPPA; |
| what does IPPA stand for | inspection, palpate, percuss, and auscultate |
| NP Assessment- interview: what are the 3 phases; def of orientation phase; def of working phase; def of termination phase; | orientation, working, termination phase; introduction, purpose of interview; nurse gathers info r/t clients health status; summarize important points, validate this with client, indicate when you will be backq |
| def of clinical manifestations | used to describe the objective and subjective data obtained from a pt that are commonly associated with a clinical problem |
| objective data is aka; subjective data is aka | signs; symptoms |
| 7 cue categories used to analyze a symptom: what are they; | location, quality, quantity, chronology, setting, aggravating/ alleviating factors, associated manis, meaning of symptom to pt |
| 7 cue categories used to analyze a symptom: location- ask; record | where do you feel it, where is it located; region of body, local radiating, superficial and deep |
| 7 cue categories used to analyze a symptom: quality- ask; record | what does it feel like; pt analogy |
| 7 cue categories used to analyze a symptom: quanity- ask ; record | how often do you have this feeling, hoe bad is it, how much is it; frequenc, volume, size extent, number |
| 7 cue categories used to analyze a symptom: chronology: ask; record | when was the first time it occured, any time of day, week month; time of onset, duration, periodicity and frequency |
| 7 cue categories used to analyze a symptom: setting- ask; record | where are you when this occurs?, what are you doing; where pt is when it occurs, what pt is doing, if symptom is rt anything |
| 7 cue categories used to analyze a symptom: aggravating/ alleviating factors- ask; record | what makes it better/ worse, any activity that seems to cause it?, what have you done for it; influence of physical and emotional activities, pt attempt to alleviate the symptoms |
| why is the nursing process important | it provides an organizing framework for the practice of nursing and the knowledge, judgment and action that that nurses bring to patient care. |
| NP Assessment- what is the purpose; what are the 2 steps of assessment; | to establish a database about client's perceived needs, health problems and responses to these problems; collection of data and analysis of data |
| NP Assessment- how does this lead to the ND; | the analysis of data leads to develop the ND and plan of care based on actual or potential health problems |
| NP Assessment- health history- def; what is ROS | major component of assessment and it is data r/t current level of wellnes, review of body system, family, health and sociocultural hx, spiritual health, and mental health; review of systems - this is info r/t each body system and any changes |
| NP Nursing diagnosis- when was the first conference held to identify nursing knowledge and establish a class of systems; what is NANDA; what does nanda do; | 1973; north american diagnosis association established in 1982; reviews and accepts nursing dx to be addedto the list |
| for clinical does nrsg dx have to be nanda | yes |
| def NIC; def NOC | nursing intervention class; nursing outcome class |
| NP Nursing Dx: def; what is the purpose | clinical judgement r/t individual, family, or community responses to actual or potential health problems/ life process; it provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable |
| NP Nursing Dx: what is the process of it; how is the data clustered | interpret and analyze meaning of assessment data; group of s/s, classified and organized,look for defining characteristics, identify client need, formulate nrsg dx |
| NP Nursing Dx: diff between nrsg dx and care plans | in nrsg dx there is an assessment then one problem is solved in the pt in the care plan there is a collection of nursing dx for the pt |
| nrsg dx vs med dx: nrsg dx- requires what intervention; what is scope of practice; how many nrsg dx; does the dx change of stay the same; what is the focus on; nurses provide what | nursing; scope of nursing practice; multiple; changes; human response; care |
| nrsg dx vs med dx: why are there multiple dx for pt | b/c we are dealing with effects of new problem on person |
| nrsg dx vs med dx: med dx- requires what intervention; what scope of practice; single of multiple dx; does dx change or stay the same; what is the focus on; what do phys provide | medical; medical scope of practice; single; stay the same; the disease; the cure |
| NP Nursing Dx: provides the basis for what; what did NANDA develop; | the selection of nursing interventions; a standardized nursing terminology for identifying, defining, and classifying pt actual or potential responses to health probs |
| NP Nursing Dx: a nursing dx is not what | a disease process, a normal need, a normal developmental level, a nursing problem, a tx or therapy |
| NP Nursing Dx: what are errors nurses make when dx | they have insufficient data used with a label, sufficient data but wrong label, invalid data, renaming a medical problem, legally inadvisable or judgmental label |
| NP Nursing Dx: the statement can be written in how many parts; the number of parts depends on what; | 1,2 or 3 statement; the nrsg dx being used; |
| NP Nursing Dx:one part statements are used for what; when is a 2 part dx acceptable; | wellnes ndx; only if the s/s data are easily accessible to other nurses caring for the patient and for risk dx; |
| NP Nursing Dx: why is risk dx a 2 part statement; when is 3 part statement used; | b/c s/s are not present (they are at risk); during the learning process |
| NP Nursing Dx: 3 part statement identifies what; what is the format for 3 part statement; what is PES | critical thinkning process that occurs in making the judgment about the pts health status; PES; problem ,etiology, s/s |
| NP Nursing Dx: PES- problem def; ex problem; etiology def; ex etiology; s/s def; ex s/s | the nrsg dx label, the term taht reflects the pattern of cues; pain; a brief description of the probable cause of the problem, contributing or r/t factors; r/t surgical incision, edema; a list of the cluster of s/s data the lead to problem; aeb isolation |
| NP Nursing Dx: what is the r/t portion of PES; what is the label portion of PES; what is the as evidenced by portion of PES | etiology; the problem; the s/s |
| NP Nursing Dx: Etiology- this is a brief description of what; the r/t must be something the nurse can what; what should not be the primary etiology; | the probable cause of the problem; tx; the medical dx- it can be secondary to it |
| NP Nursing Dx: s/s- def; ex; | this is a list of data that lead nurse to pinpoint the problem; aeb verbalization of pain, isolation, withdrawal secondary to colon resection |
| NP Nursing Dx: Types- actual: def; supported by what; how many parts; example; | describes human responses to current health problems; defining characteristics; 3; impaired skin integrity r/t prolonged immobility secondary to fx pelvis, aeb a 2 cm lesion on back |
| NP Nursing Dx: Types- risk/high risk: def; how many part statement; example | describes human responses to problem that may develop in a vulnerable individual, family or community; 2 parts; risk for injury r/t lack of awareness of hazards |
| NP Nursing Dx: Types- possible: def; how many part statement; example | describe a suspected problem requiring additional data; 2 parts; possible disturbed body image r/t isolatinf behaviors psot surgury |
| NP Nursing Dx: Types- wellness: def; how many part statement; example | reflects transition from a specific level of wellness to a higher level of wellness; one part; readiness for enhanced nutrition |
| NP Nursing Dx: Types- syndrome: def; how many part statement; what are the 5 ones | cluster of predicted actual or high risk nursing dx r/t a certain event of situation; usually 1 part sometimes 2; rape trauma, disuse, post-trauma, relocation stress, impaired environmental interpretation syndrome |
| NP Nursing Dx: Types- collaborative: def; how many part statement; who prescribes tx; written how | actual or potential phys. complications that can result from disease, trauma, tx or diagnostic studies for whicn nurses intervene in collaboration w/ personnel of other health care disciplines; one part; nurse and doc; risk for complication |
| NP nursing DX: s/s: s/s are aka; def of major s/s; def minor | defining characteristics; are those s/s that are usually present when the dx exists; evidence of a possible nursing dx |
| NP Planning: NOC- def; behavior is measured along what; | research basedm standardized language for nursing outcomes to eval effectiveness of nursing interventions; a continuum to eval progress towards achieving the outcome |
| what is the diff between a goal or outcome | a goal is broad, outcome is focused |
| NP Planning: what needs should be met first; what is pt outcome; | physical b4 phsyological; describe to what degree the patients response identified in the nursing dx should be prevented or changed as a result of nrsg care |
| NP Planning: goals- what are the guidlines; how many behaviors per goal; | realistic, mutual, include short and long term goals, include all 5 components, use measurable observable verbs; one (ex no not wirte denies pain and N at end of shift); |
| NP Planning: def of short term goals; def of long term goals | progrss towards LT goals; usually discharge goals |
| NP Planning: goals- what are the components of goals; | subject, verb, condition, criteria, time; |
| NP Planning: goals- what are ex of measurable verbs | identify, list, describe, discuss, perform, demonstrate, give ,administer, state, verbalize, sit, stand, walk, relate, share, exoress, has absense of, exercise, communicate, explain, cough |
| NP nrsg inverventions: choosing interventions must be r/t what; interventions have to refer to what; nurse must have what to perform interventions | altering the etiological factors; research articles or evidence-based practice protocols; skills |
| NP nrsg inverventions: def; | is any tx based on clinical judgement and knowledge that a nurse performs to enhance pt outcomes |
| NP nrsg inverventions: what is the nursing order for interventions | what, when, how often, how long and where |
| NP evaluation: what is compared; what is done next with problem; | the pt response to goals; continue, revise, or discontinue problem |
Created by:
jmkettel
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