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54 Cards in this Set

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The Nursing Process

Is a way of thinking and acting based on the scientific method(step by step process used by scientist to solve problems)

Scientific Method

Step by step process used by a scientist to solve problems

The Five Components of the Nursing Process?

Assessment


Nursing Diagnosis


Planning


Implementation


Evaluation

NFLPN

National Federation of Licensed Practical Nurse

Clinical Reasoning

Skills that result in solid Clinical Judgement

What does critical mean?

Means requiring careful judgment

Thinking term used in (Critical Thinking) means

Thinking means to reason

The Term "Critical Thinking" is defined as?

Directed, purposeful, mental activity by which you evaluate ideas, construct plans, and determine desired outcomes.

Critical Thinking inside the clinical setting?

is called clinical reasoning, which is necessary to make reliable observations regarding health status and to draw sound conclusion from the data obtained

Clinical Judgment

is the outcome of clinical reasoning

Decision making

is choosing the best actions to meet a desired goal and is part of critical thinking

EBP

Evidence based practice

KSA

Knowledge, Skills, Attitudes

Assessments (Data Collection)

Collecting, organizing, documentation, and validating data about a patients health status. Assessment data is gathered from the patient, family, doctor, diagnostic tests.

Nurse Diagnosis

Assessment data is sorted and analyzed so that specific, actual, and potential health problems are identified. Specific nursing diagnosis are chosen for the patients care plan.

Planning

A series of steps the nurse and the patient set priorities and goals to eliminate or diminish the identified problems.

Implementation

Carrying out the nursing interventions in a systematic way. The patients response to the care given is documented

Evaluation

Assessing the patients response to the nursing interventions. Compared with the expected outcomes to determine whether they have been achieved.

Priority

More and important then something else at the time

Prioritizing includes?

placing nursing diagnoses or nursing interventions in order of importance

The Three Methods of Data Collection Can Be?

Structured format from the 11 functional health patterns


Focused Assessment-Concerned with one specific problem


Maslows Hierarchy of basic needs-assess every area

Interview

conversation in which facts are obtained about a patient

Subjective Data

Data obtained from the patient verbally

Objective Data

Information obtained through the senses and hands on physical examination, vital signs, diagnostic test are examples

Interview

focused on gathering information/data and is not a social interaction

Interviews are assessed in such a way?

The opening= Rapport


The Body=necessary questions are obtained


The Closing= finish and ask if the patient has any questions

Inspection

Portion of the physical examination= Looking

Auscultation

Listening

Palpation

touching

Percussion

thumping

Long Term Care Facility


ADL's

Activities of Daily Living


In which a patient will need assessment

Cues

Pieces of data or information that influence decisions such as signs and symptoms

Nursing Diagnosis

Statement indicates the patients actual health status or the risk of a problem developing, the causative or related factors, and specific characteristics (Signs and Symptoms)

NANDA-I

National American Nursing Diagnosis Association-International

Etiological Factors

the cause of the problem

Defining Characteristics

Signs and Symptoms that must be present for a particular nursing diagnosis to be appropriate for the patient

Signs

Abnormalities that can be verified by repeat examination and are objective data

Symptoms

Are factors the patient has said are occurring that cannot be verified by examination. i.e. symptoms are subjective data

Nursing diagnosis

defines the patients response to illness

Medical Diagnosis

Labels an illness

r/t means

related to

Goals

broad idea of what is to be achieved through the nursing intervention

Short term goals

are those that are achieved in 7-10 days or before discharge

Long term goals

often relate to rehabilitation

Expected outcomes

Derived from goals, specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention

Expected Outcome

should be realistic and attainable and should have a defined time line, collaboration with the patient regarding the expected outcomes is important

Time-flexible

can be done anytime

Time-fixed

must be done at a set time

Independent Nursing Action

does not require a physicians order

Dependent Nursing Action

requires a doctors order

Interdependent Action

Collaborating with health professionals, assisting with physical therapy by helping the patient exercise

Remember

The nurse performs any invasive procedure and any sterile procedure

Remember

Nurses notes must indicate that the nursing care plan has been carried out, if not documented action is considered not done

Outcome-based quality improvement QBQI

Improvement of the quality of performance