Unit 1: Chapter 4

Conceptual frameworks for the basis of nursing practice:

- Henderson's Complementary Supplement Model - Roger's Life Process Theory - Roy's Adaptation Model - Canadian Nurses Association Testing Service

The wording of an actual nursing diagnosis takes the form of a three-part statement. These statements consist of the following:

- a patient problem summarizing the issue - the contributing factors or cause (may include deficits in ADLs or the medical diagnosis - the defining characteristics

List the four types of nursing diagnosis:

- actual - risk/high-risk - health promotion and wellness - syndrome

List the five steps of the nursing process model:

- assessment - nursing diagnosis - planning - implementation - evaluation

List the three types of nursing actions within the nursing process:

- dependent - interdependent - independent

Two nursing diagnosis that apply to all types of medication prescribed are:

- insufficient knowledge (actual, risk) related to the medication regimen (patient education) - noncooperation (actual, risk) related to the patient's value system, cognitive ability, cultural factors, or economic resources

Problem situations are organized into five categories:

- pathphysiologic - treatment related - personal - environmental - maturational

List the four phases of the planning stage of the nursing process:

- priority setting - development of measurable goal and outcome statements - formulation of nursing interventions - formulation of anticipated therapeutic outcomes that can be used to evaluate the patient's status

List the five currently approved syndrome diagnosis:

- rape-trauma syndrome - disuse syndrome - posttrauma syndrome - relocation stress syndrome - impaired environmental interpretation syndrome

The risk/high-risk nursing diagnosis statement consists of two parts:

- the diagnostic label from the NANDA-I approved list - the risk factors that make the individual or group more susceptible to the development of the problem

The fifth and final phase of the nursing process, involved the nurse determining whether the expected outcomes were met.

evaluation

The application of data from scientific research to make clinical decisions about the care of individual patients.

evidence-based practice

The process of collecting additional data specific to a patient or family that validates a suggested problem or nursing diagnosis.

focused assessment

Type of nursing diagnosis - a clinical judgment about an individual, a group, or a community in transition from a specific level of wellness to a higher level of wellness.

health promotion and wellness nursing diagnosis

While priority setting, care delivery options are often organized in relation to their direct effects on the maintenance of _____________________.

homeostasis

The fourth phase of the nursing process, consists of carrying out the established plan of care.

implementation

Actions that are not prescribed by a healthcare provider that a nurse can provide by virtue of the education and licensure that he or she has attained.

independent actions

Actions that the nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health.

interdependent actions

Starts with an action word that is followed by the behavior or behaviors to be performed by the patient or the patient's family within a specific amount of time.

measurable goal statement

A statement of the patient's alterations in structure and function, results in the diagnosis of a disease or disorder that impairs normal physiologic function.

medical diagnosis

The written or computer generated document that evolves from the planning phase of the nursing process.

nursing care plan

Systems designed to provide a standardized language of reporting and analyzing nursing care delivery that has been individualized for the patient (ex: NIC, NOC, Nursing Minimum Data Set).

nursing classification systems

Second phase of the nursing process; a clinical judgement about an individual, family, or community responses to actual or potential health problems/life processes.

nursing diagnosis

Foundation for the clinical practice of nursing which provides the framework for consistent nursing actions and involves the use of a problem-solving approach rather than an intuitive approach.

nursing process

Information gained from observations that the nurse makes with the use of physiologic parameters.

objective data

A nursing action is a statement that describes nursing interventions that are applicable to any patient. Nursing ___________________ describe how specific actions, including time intervals, will be implemented for an individual patient.

orders

Third phase of the nursing process in which meeting patient's needs and addressing diagnosed problems is the focus.

planning

A collaborative problem statement is worded as a ________________ __________________, which is abbreviated as PC.

potential complication

Whenever the patient is able to provide reliable information, they should be used as the _____________ source of information.

primary

A health promotion or wellness nursing diagnosis statement only has a one-part label which is initiated by this phrase.

readiness for enhanced

Type of nursing diagnosis - a clinical judgement that an individual, a family, or a community is more susceptible to the problem than others in the same or a similar situation. Supported by risk factors that increase vulnerability.

risk/high-risk nursing diagnosis

Information obtained by a source other than the patient (ex: relatives, significant others, medical records, laboratory reports, nurses' notes, other healthcare professionals).

secondary sources

Pieces of information provided by the patient

subjective data

Type of nursing diagnosis - cluster actual or high-risk signs and symptoms that are predictive of certain circumstances or events, causative or contributing factors for the diagnosis are contained in the diagnostic label.

syndrome nursing diagnosis

Sources of information which provide an accurate depiction of the characteristics of a disease, the nursing interventions and diagnostic tests used, the pharmacologic treatment prescribes, the dietary interventions and physical therapy undertaken, and other factors pertinent to the patient's care requirements.

tertiary sources

T/F: The goals that are established should be nursing goals for the patient.

F (they should be patient goals)

Assessment includes taking a drug history for 3 reasons:

- to evaluate the patient's need for medication - to obtain his or her current and past use of over-the-counter medications, prescription medications, herbal products, and street drugs - to identify problems related to drug therapy

NIC

Nursing Interventions Classification

NOC

Nursing Outcomes Classification

________________ _________________ are suggested by the etiology of the problems identified in the nursing diagnosis, and they are used to implement plans

Nursing actions

___________________ statements are measured along the continuum of care are are developed to document the effectiveness of the care delivered.

Outcome

T/F: Assessment starts when the patient is admitted and continues until the patient is discharged from care.

T

T/F: The focus of all nursing care is to help individuals maximize their potential for maintaining the highest possible level of independence for the meeting of self-care needs.

T

Nursing diagnosis based on human responses to health conditions and life processes that exist in an individual, a family, or a community. Supported by defining characteristics that cluster in patterns of related cues or inferences.

actual nursing diagnosis

Outcome statements are expressed as

anticipated therapeutic statements or expected outcome statements

First phase of the five-step nursing process, the problem-identifying phase of the nursing process.

assessment

Detailed explanations of the purpose for which a drug is intended, assists the nurse to identify common and adverse effects and drug interactions for patient monitoring.

drug monographs

When the nurse cannot legally order the definitive interventions required under the presenting circumstances a ____________________ problem exists.

collaborative

Measures of care that are tracked to show how often hospitals and healthcare providers use the care recommendation identified by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia or for patients who are undergoing surgery.

core measures

Standardized, automated care plans that integrate standards, interventions, goals, and outcomes into the patient's electronic medical record.

critical pathways

Manifestations or signs and symptoms that relate to a particular patient problem are known as.

defining characteristics

Actions performed by the nurse on the basis of the healthcare provider's orders.

dependent actions