NUR 1020C (Ch 5-9)

nursing process

-A systemic, rational method of critical thinking used by nurses to develop individualized care plans and provide care for patients -term was first used by Lydia Hall in 1955 -In 1973, the ANA identified five steps of the nursing process in its Standards of Clinical Practice (1991) -Steps include: 1. Assessment 2. Diagnosis 3. Planning 4. Implementation 5. Evaluation

Readiness for Enhanced

-All risk NANDA-I nursing diagnoses begin with the words: Risk for. -All health promotion NANDA-I nursing diagnoses begin with the words: ____________________

Risk for.

-All risk NANDA-I nursing diagnoses begin with the words: _____________________ -All health promotion NANDA-I nursing diagnoses begin with the words: Readiness for Enhanced

Primary data

-Data collected directly from patient -try and collect this data first before secondary data -ex: Alert and oriented adult patient give primary subjective data during the interview

Secondary data

-Data collected from friends/family, or other members of healthcare team -Data obtained from patient's chart, medical records, results of laboratory and diagnostic tests, and literature reviews. -ex: Family can give secondary subjective data in an interview

a diagnostic label; related factors; defining characteristics

-Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines: ~Problem-focused nursing diagnoses parts: 1) ________________ 2) _______________ 3) _______________ ~Risk nursing diagnoses parts: 1) a diagnostic label 2) risk factors preceded by the phrase 'as evidence by' ~Health promotion nursing diagnoses parts: 1) the diagnostic label 2) defining characteristics

a diagnostic label; risk factors preceded by the phrase 'as evidence by'

-Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines: ~Problem-focused nursing diagnoses parts: 1) a diagnostic label 2) related factors 3) defining characteristics ~Risk nursing diagnoses parts: 1) _______________ 2) ______________ ~Health promotion nursing diagnoses parts: 1) the diagnostic label 2) defining characteristics

the diagnostic label; defining characteristics

-Each type of nursing diagnostic statement contains sections or parts to comply with NANDA-I guidelines: ~Problem-focused nursing diagnoses parts: 1) a diagnostic label 2) related factors 3) defining characteristics ~Risk nursing diagnoses parts: 1) a diagnostic label 2) risk factors preceded by the phrase 'as evidence by' ~Health promotion nursing diagnoses parts: 1) ________________ 2) ________________

NANDA International

-Group working since 1970 to establish a comprehensive list of nursing diagnoses -goals are to generate, name, implement nursing diagnostic categories; revise the taxonomy, promoting research to validate diagnostic labels, and encourage nurses to use taxonomy in practice

Related factors

-The second part of the NANDA-I problem-focused nursing diagnosis consists of related factors. -_____________ are the underlying cause or etiology of a patient's problem -Reviewing patient history can help nurse determine ____________

problem-focused nursing diagnoses

-Three types of NANDA-I nursing diagnostic statements 1. ________________________: are clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community. 2. 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 3. health promotion nursing diagnosis- are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential.

risk nursing diagnosis

-Three types of NANDA-I nursing diagnostic statements 1. problem-focused nursing diagnoses: are clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community. 2. ________________- identify risk factors that are vulnerabilities of an individual, family, group, or community for developing negative human responses to health conditions or life processes 3. health promotion nursing diagnosis- are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential.

health promotion nursing diagnosis

-Three types of NANDA-I nursing diagnostic statements 1. problem-focused nursing diagnoses: are clinical judgements about undesirable human responses to health conditions or life processes that occur in an individual, family, group, or community. 2. 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 3. ________________- are clinical judgments concerning the motivation and desire of an individual, family, group, or community to increase well-being and to actualize human health potential.

Subjective data (symptoms)

-difficult to validate -gathered through interview through what patient says -should be documented as direct quotations

Nursing Diagnosis

-is the nurse's clinical judgement about a client's response to actual or potential health conditions or needs. (ANA, 2018) -is the second step to nursing process -in this step the nurse makes clinical decisions about a patient's experiences and responses to problems or life events identified during the data collection process

Body Systems Model

-organizes data based on ech body system -it follows a sequence like the medical model for physical examination -focuses on abnormalities of following anatomic systems: 1. Integumentary System 2. Respiratory System 3. Cardiovascular System 4. Nervous System 5. Musculoskeletal System 6. Gastrointestinal System 7. Genitourinary System 8. Reproductive System 9. Immune System

Gordon's Functional Health Patterns

-organizes data in a holistic way -beneficial when organizing vast amounts of patient information and when clustering related data before formulating nursing diagnoses, patient goals, and treatment outcomes

Maslow's Hierarchy of Needs (1987)

-theory that says physiological needs are more important than other needs like self-esteem -physiological needs in order: Airway patency, breathing, circulation, oxygen level, nutrition, fluid intake, body temp regulation, warmth, elimination, shelter, sexuality, infection, pain level

inferences

A conclusion reached on the basis of evidence and reasoning -a nurse must avoid making _________ based on personal assumptions or judgments.

Independent interventions

Activities that nurses are licensed to initiate on the basis of their knowledge and skills ex: ordering a heel protector and initiating prevention measure from skin breakdown

Outcome indicators

An indicator that assesses what happens or does not happen to a patient following a process; agreed upon desired patient characteristics to be achieved; undesired patient conditions to be avoided

the nurse has not completed a thorough review of the patient's assessment information or is missing important data

Clustering unrelated data most often occurs when ______________ ____________________________________________.

chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal

Emergency Severity Index (ESI): -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +Severe trauma, Cardiac arrest, Respiratory arrest, seizure ~Level 2-Emergent: High risk; imminent life-threatening +________________________________________________ ~Level 3- Urgent: Moderate risk; potential life-threatening +abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism ~Level 4- Semi-urgent: Low risk, stable health condition +twisted ankle injury +R/O urinary tract infection ~Level 5- Non-urgent, Lower risk +Poison ivy, cold symptoms, minor aches and pains

abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism

Emergency Severity Index (ESI): -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +Severe trauma, Cardiac arrest, Respiratory arrest, seizure ~Level 2-Emergent: High risk; imminent life-threatening +chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal ~Level 3- Urgent: Moderate risk; potential life-threatening +__________________________________________ ~Level 4- Semi-urgent: Low risk, stable health condition +twisted ankle injury +R/O urinary tract infection ~Level 5- Non-urgent, Lower risk +Poison ivy, cold symptoms, minor aches and pains

twisted ankle injury, R/O urinary tract infection

Emergency Severity Index (ESI): -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +Severe trauma, Cardiac arrest, Respiratory arrest, seizure ~Level 2-Emergent: High risk; imminent life-threatening +chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal ~Level 3- Urgent: Moderate risk; potential life-threatening +abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism ~Level 4- Semi-urgent: Low risk, stable health condition +______________________________ ~Level 5- Non-urgent, Lower risk +Poison ivy, cold symptoms, minor aches and pains

Poison ivy, cold symptoms, minor aches and pains

Emergency Severity Index (ESI): -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +Severe trauma, Cardiac arrest, Respiratory arrest, seizure ~Level 2-Emergent: High risk; imminent life-threatening +chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal ~Level 3- Urgent: Moderate risk; potential life-threatening +abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism ~Level 4- Semi-urgent: Low risk, stable health condition +twisted ankle injury +R/O urinary tract infection ~Level 5- Non-urgent, Lower risk +________________________________________________

Severe trauma, Cardiac arrest, Respiratory arrest, seizure

Emergency Severity Index (ESI): -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +________________________________________________________ ~Level 2-Emergent: High risk; imminent life-threatening +chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal ~Level 3- Urgent: Moderate risk; potential life-threatening +abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism ~Level 4- Semi-urgent: Low risk, stable health condition +twisted ankle injury +R/O urinary tract infection ~Level 5- Non-urgent, Lower risk +Poison ivy, cold symptoms, minor aches and pains

2-3 years

Every __________ the NANDA-I and ICNP revise and evaluate their taxonomies based on nursing research conducted to validate current and evolving nursing practice.

observation

Methods of Assessment: -_____________: using the senses of sight, hearing, and smell during the interview helps the nurse to gather information ~ex: clothing, personal hygiene, a limp, a wound, etc. -patient interview: a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories. ~has three phases- orientation, working, and termination -physical assessment: this is objective data

patient interview

Methods of Assessment: -observation: using the senses of sight, hearing, and smell during the interview helps the nurse to gather information ~ex: clothing, personal hygiene, a limp, a wound, etc. -_____________: a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories. ~has three phases- orientation, working, and termination -physical assessment: this is objective data

physical assessment

Methods of Assessment: -observation: using the senses of sight, hearing, and smell during the interview helps the nurse to gather information ~ex: clothing, personal hygiene, a limp, a wound, etc. -patient interview: a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories. ~has three phases- orientation, working, and termination -_____________: this is objective data

patient interview, health history, and physical assessment

Nursing Process: Assessment -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: _________________ ~Primary Data: info directly from patient ~Secondary Data: info from family/friends, other providers, medical records, test results, etc. ~Subjective Data: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~Objective Data: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

Objective Data

Nursing Process: Assessment -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: patient interview, health history, and physical assessment ~Primary Data: info directly from patient ~Secondary Data: info from family/friends, other providers, medical records, test results, etc. ~Subjective Data: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~_________: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

Subjective Data

Nursing Process: Assessment -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: patient interview, health history, and physical assessment ~Primary Data: info directly from patient ~Secondary Data: info from family/friends, other providers, medical records, test results, etc. ~__________: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~Objective Data: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

Secondary Data

Nursing Process: Assessment -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: patient interview, health history, and physical assessment ~Primary Data: info directly from patient ~___________: info from family/friends, other providers, medical records, test results, etc. ~Subjective Data: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~Objective Data: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

Primary Data

Nursing Process: Assessment -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: patient interview, health history, and physical assessment ~____________: info directly from patient ~Secondary Data: info from family/friends, other providers, medical records, test results, etc. ~Subjective Data: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~Objective Data: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

Standing orders

Nursing Process: Implementation -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~___________: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

Protocols

Nursing Process: Implementation -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~__________: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

Clinical pathways (care maps)

Nursing Process: Implementation -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~____________: multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

All interventions must be documented; allows nurse to evaluate the effectiveness of interventions

Nursing Process: Implementation -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: _____________________ -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

Dependent

Nursing Process: Implementation -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~______________: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

Independent

Nursing Process: Implementation -Interventions ~______________: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

patient/groups focused, realistic, and measurable

Nursing Process: Planning -the nurse prioritizes identified patient or group nursing diagnoses, establishes short and long term goals, chooses outcome indicators (NOC), and identifies interventions to address specific goals. ~short term goals (STG): achievable within less than 1 week ~long term goals (LTG): take weeks or months to achieve ~All goals must be __________________________________________ ~Outcome identification involves listing behaviors or observable items that indicate attainment of a goal. ++Nursing Outcome Classification (NOC) is a resource used for outcome identification ~Nursing Interventions Classification (NIC) is a resource used for multidisciplinary interventions linked to specific nursing diagnoses and the NOC.

Nursing Interventions Classification (NIC)

Nursing Process: Planning -the nurse prioritizes identified patient or group nursing diagnoses, establishes short and long term goals, chooses outcome indicators (NOC), and identifies interventions to address specific goals. ~short term goals (STG): achievable within less than 1 week ~long term goals (LTG): take weeks or months to achieve ~All goals must be patient/groups focused, realistic, and measurable ~Outcome identification involves listing behaviors or observable items that indicate attainment of a goal. ++Nursing Outcome Classification (NOC) is a resource used for outcome identification ~_________ is a resource used for multidisciplinary interventions linked to specific nursing diagnoses and the NOC.

Nursing Outcome Classification (NOC)

Nursing Process: Planning -the nurse prioritizes identified patient or group nursing diagnoses, establishes short and long term goals, chooses outcome indicators (NOC), and identifies interventions to address specific goals. ~short term goals (STG): achievable within less than 1 week ~long term goals (LTG): take weeks or months to achieve ~All goals must be patient/groups focused, realistic, and measurable ~Outcome identification involves listing behaviors or observable items that indicate attainment of a goal. ++_______________ is a resource used for outcome identification ~Nursing Interventions Classification (NIC) is a resource used for multidisciplinary interventions linked to specific nursing diagnoses and the NOC.

Outcome identification

Nursing Process: Planning -the nurse prioritizes identified patient or group nursing diagnoses, establishes short and long term goals, chooses outcome indicators (NOC), and identifies interventions to address specific goals. ~short term goals (STG): achievable within less than 1 week ~long term goals (LTG): take weeks or months to achieve ~All goals must be patient/groups focused, realistic, and measurable ~___________ involves listing behaviors or observable items that indicate attainment of a goal. ++Nursing Outcome Classification (NOC) is a resource used for outcome identification ~Nursing Interventions Classification (NIC) is a resource used for multidisciplinary interventions linked to specific nursing diagnoses and the NOC.

Diagnosis

Nursing Process: __________ -a description of what a nurse observes or discovers while assessing a patient or group. -identifies a problem, potential problem, or opportunity of improvement. -ANA states "nursing diagnosis is the nurse's clinical judgement about a client's response to actual or potential health conditions or needs." -ex: sleep deprivation, risk for infection, health-seeking behavior, etc.

Evaluation

Nursing Process: ____________ -focuses on the patient or group and the patient's or group's response to nursing interventions and goal or outcome attainment -Is not a record of the care that was implemented -during this phase, nurses determine whether or not short- and long-term goals were met, and desired outcomes were achieved.

Implementation

Nursing Process: _________________ -Interventions ~Independent: tasks within the nursing scope of practice that the nurse may undertake without a physician or PCP order ~Dependent: tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider to be implemented ~Collaborative -Care ~Direct ~Indirect -Documentation: All interventions must be documented; allows nurse to evaluate the effectiveness of interventions -NIC -Care plans ~Clinical pathways (care maps): multidisciplinary resources designed to guide patient care. ~Protocols: 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. ~Standing orders: are written by physicians and list specific actions to be taken by a nurse or other health provider when access to a physician is not possible or the situation is standard.

Planning

Nursing Process: __________________ -the nurse prioritizes identified patient or group nursing diagnoses, establishes short and long term goals, chooses outcome indicators (NOC), and identifies interventions to address specific goals. ~short term goals (STG): achievable within less than 1 week ~long term goals (LTG): take weeks or months to achieve ~All goals must be patient/groups focused, realistic, and measurable ~Outcome identification involves listing behaviors or observable items that indicate attainment of a goal. ++Nursing Outcome Classification (NOC) is a resource used for outcome identification ~Nursing Interventions Classification (NIC) is a resource used for multidisciplinary interventions linked to specific nursing diagnoses and the NOC.

Assessment

Nursing Process: _____________________ -The organized and ongoing appraisal of a patient's well-being. -Collection of data from multiple sources: patient interview, health history, and physical assessment ~Primary Data: info directly from patient ~Secondary Data: info from family/friends, other providers, medical records, test results, etc. ~Subjective Data: symptoms; gathered from patient interview and health history; documented as "direct quotations" ~Objective Data: signs; from medical records, lab or diagnostic tests results; most collected through physical assessment; can be seen, measured, and tested

True (123)

Nursing diagnoses consider a patient's situation more holistically than medical diagnoses, including how the patient responds to situations. ~they take into account a patient's strengths and resources- not just the medical problem identified. True or False? (123)

Head-to-toe model

Organizing assessment data in a cephalic to caudal pattern. Includes data related to psychosocial concerns, emotional status, cultural and ethnic influences, and living conditions. -more of a medical model -Nurse documents in this order: 1. info regarding patient's general health status 2. vital sign assessment 3. objective and subjective data 4. physical assessment data (Documentation begins with head and ends with lower extremities)

patient needs and determine the extent to which the patient wants to be involved in care planning

Patient Interview: Orientation Phase -This phase is essential for establishing trust between nurse and patient, which affects all future interactions. -Demographic data should be collected using focused and close-ended questions -Nurse must identify _________________________________________________ -Keep these considerations in mind: ~The nurse and patient should be seated at eye level if feasible; also keep consideration of HIPAA ~Make sure to communicate professionally ~sit close and lean in slightly towards patient ~listen attentively and maintain eye contact with friendly demeanor ~use moderate rate of speech and tone of voice

Demographic data

Patient Interview: Orientation Phase -This phase is essential for establishing trust between nurse and patient, which affects all future interactions. -____________ should be collected using focused and close-ended questions -Nurse must identify patient needs and determine the extent to which the patient wants to be involved in care planning -Keep these considerations in mind: ~The nurse and patient should be seated at eye level if feasible; also keep consideration of HIPAA ~Make sure to communicate professionally ~sit close and lean in slightly towards patient ~listen attentively and maintain eye contact with friendly demeanor ~use moderate rate of speech and tone of voice

Review of Systems

Patient Interview: Working Phase ~__________: questioning patient about all body systems in a systematic manner as part of the nursing assessment +subjective data +after data collected, goals are established +ex: "Are you experiencing any difficulty breathing?" or "Do you ever experience diarrhea or constipation?"

Health History

Patient Interview: Working Phase ~___________: All pertinent information that can guide the development of a patient-centered plan of care +subjective data +includes demographics (orientation phase), chief complaint, allergies, medications, history of current illnesses, medical/family/social history

Health Promotion

Patient Interview: Working Phase ~___________: identify behaviors of patient motivated by a personal desire to increase well-being and health potential and any risk factors +ex: do they exercise; are they a fall risk; do they need nutritional guidelines

Working Phase

Patient Interview: _______________ -focus on the purpose of interaction -use direct questions (then expand to open questions) to gather data about a patient's health history or during the review of body systems, and health promotion

Termination Phase

Patient Interview: _________________ -end of interview -summarize and validate information taken during interview -patient can add additional info -nurse should describe next steps after interview

Orientation Phase

Patient Interview: ___________________ -This phase is essential for establishing trust between nurse and patient, which affects all future interactions. -Demographic data should be collected using focused and close-ended questions -Nurse must identify patient needs and determine the extent to which the patient wants to be involved in care planning -Keep these considerations in mind: ~The nurse and patient should be seated at eye level if feasible; also keep consideration of HIPAA ~Make sure to communicate professionally ~sit close and lean in slightly towards patient ~listen attentively and maintain eye contact with friendly demeanor ~use moderate rate of speech and tone of voice

inspection (1), palpation (2), percussion (3), and auscultation (4)

Physical Assessment -objective data -diagnostic test, x-rays, lab results are reviewed by nurse if they were ordered before patient was seen -vital signs are taken and recorded at the beginning of examination -assessment techniques are used: _______________________________ ~techniques are performed in this order for each body system except the abdomen; inspection (1), auscultation (2), palpation (3), percussion (4) (it is this way as to avoid stimulating the bowl)

inspection (1), auscultation (2), palpation (3), percussion (4)

Physical Assessment -objective data -diagnostic test, x-rays, lab results are reviewed by nurse if they were ordered before patient was seen -vital signs are taken and recorded at the beginning of examination -assessment techniques are used: inspection (1), palpation (2), percussion (3), and auscultation (4) ~techniques are performed in this order for each body system except the abdomen; ____________________________ (it is this way as to avoid stimulating the bowl)

Auscultation

Physical Assessment: ____________ -a technique of listening with the assistance of a stethoscope to sounds made by organs or systems such as the heart, blood vessels, lungs, and abdominal cavity.

Percussion

Physical Assessment: ________________ -involves tapping the patient's skin with short, sharp strokes that cause a vibration to travel through the skin; meant to help determine density of the structures underneath the skin -an abnormal sound could mean that there is fluid or air or blood in the structure.

Inspection

Physical Assessment: ________________ -involves the use of vision, hearing, and smell to closely scrutinize characteristics of the whole person and individual body systems -Symmetry should be assessed by comparing the right and left sides of the body to detect anatomic deviations

Palpation

Physical Assessment: ________________ -uses touch to assess body organs and skin texture, temperature, moisture, turgor, tenderness, and thickness. -can be used to determine organ size and location, and any distention or masses, and vibrations or pulsation

one

Regardless of the type of NANDA-I nursing diagnosis statement being written, only ________ label should be used in each statement. ex: do not put "Anxiety and Diarrhea related to..." instead put "Anxiety related to..." and another one would say "Diarrhea related to..."

NANDA International (NANDA-I)

The North American Nursing Diagnosis Association; organized in 1973, this organization formally identifies, develops, and classifies nursing diagnoses; developed a model for organizing nursing diagnoses for documentation, auditing, and communication purposes -Complete ______ taxonomy is published in Nursing Diagnoses: Definitions and Classifications

cyclic

The nursing process is _______ instead of linear. As a patient's condition changes, so does the way a professional nurse thinks about a patient's needs, forcing modification of earlier plans of care.

True (45)

The patient's primary nurse is often the cental figure in coordinating collaborative care. True or False? (45)

defining and describing the independent area of nursing practice

The use of nursing diagnoses facilitates clear communication of patient needs and promotes professional accountability and autonomy by _____________________________.

Focused Assessment

Types of Physical Assessment: -___________- a brief physical examination conducted at the beginning of an acute care setting work shift to establish current patient status or during ongoing patient encounters in response to a specific patient concern. ~most common type of assessment ~may be conducted when signs indicate a change in a patient's condition or the development of a new complication

Emergency Assessment

Types of Physical Assessment: -______________- type of rapid focused assessment conducted when addressing a life-threatening or unstable situation ~done when time is of essence; priorities of care need to be established in few seconds or minutes ~Triage is form of this assessment and is a classification of patients according to treatment priority; conducted in emergency department; most use Emergency Severity Index (ESI)

Comprehensive Assessment

Types of Physical Assessment: -________________- includes a thorough interview, health history, review of systems, and physical head-to-toe assessment; also include a variety of lab and diagnostic tests

Assessment

What is the first step in nursing process?

holistic approach

Within traditional medicine, a manner of understanding health such that it encompasses all aspects - physical, mental, social, and spiritual - of a person's life.

Face-to-face communication

_____________ is the most effective method of providing patient education for older adults.

Collaboration and delegation

_____________ of care are integral to implementation step of the nursing process.

goal characteristics

____________________: Realistic- considers the patient's physical, mental, and spiritual condition. Patient-centered- specifies the activity the patient is to exhibit or demonstrate to indicate goal attainment. Measurable- specific with numeric parameters Time-limited- needs a time for evaluation

Physical Assessment

_____________________ -objective data -diagnostic test, x-rays, lab results are reviewed by nurse if they were ordered before patient was seen -vital signs are taken and recorded at the beginning of examination -assessment techniques are used: inspection (1), palpation (2), percussion (3), and auscultation (4) ~techniques are performed in this order for each body system except the abdomen; inspection (1), auscultation (2), palpation (3), percussion (4) (it is this way as to avoid stimulating the bowl)

Methods of Assessment

_____________________________: -observation: using the senses of sight, hearing, and smell during the interview helps the nurse to gather information ~ex: clothing, personal hygiene, a limp, a wound, etc. -patient interview: a formal, structured discussion in which the nurse questions the patient to obtain demographic information, data about current health concerns, and medical and surgical histories. ~has three phases- orientation, working, and termination -physical assessment: this is objective data

Emergency Severity Index (ESI)

___________________________________--: -A five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. ~Level 1- Resuscitation: Critical, life-threatening condition +Severe trauma, Cardiac arrest, Respiratory arrest, seizure ~Level 2-Emergent: High risk; imminent life-threatening +chest pain, possible stroke, subarachnoid hemorrhage, suicidal, homicidal ~Level 3- Urgent: Moderate risk; potential life-threatening +abdominal pain, hip fracture, R/O appendicitis and venous thromboembolism ~Level 4- Semi-urgent: Low risk, stable health condition +twisted ankle injury +R/O urinary tract infection ~Level 5- Non-urgent, Lower risk +Poison ivy, cold symptoms, minor aches and pains

Diagnosis label (NANDA-I)

a concise term or phrase that represents a pattern of related, clustered data -The first section of every NANDA-I nursing diagnosis statement. -A nurse must be familiar with the patient's signs and symptoms and the etiology of any problems, potential problems, or needs before determining an appropriate nursing _______________.

cue(s)

a hint or an indication of a potential disease process or disorder -All _____ must be interpreted and validated to verify the data's accuracy

Nursing Outcomes Classification (NOC)

a 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 intervention".

dependent nursing interventions

actions that require an order from a physician or another health care professional ex: orders for oxygen administration, dietary requirements, medications, and diagnostic tests

EMR (electronic medical record)

an electronic document that contains patient health information, gathered from different sources -includes identification of nursing diagnoses' from ICNP and other organizations

Characteristics of Nursing Process

analytical, dynamic, organized, outcome oriented, collaborative, adaptable

evidence-based practice (EBP)

clinical decision making that integrates the best available research with clinical expertise and patient characteristics and preferences

defining characteristics

cues or clusters of related assessment data that are signs, symptoms, or indications of an actual or health-promotion nursing diagnosis

risk factors

environmental, physical, psychological, or situational concerns that increase a patient's vulnerability to a potential problem or concern

Nursing Process

five-step systematic method for giving patient care; involves assessing, diagnosing, planning, implementing, and evaluating (ADPIE)

collaborative interventions

interdependent nursing actions performed jointly by nurses and other members of the health care team ex: physical therapy, home health care, personal care, spiritual counseling

Clustering

involves organizing patient assessment data into groupings with similar underlying causes; this is to support specific nursing diagnoses. -it is common to apply several nursing diagnoses to one patient depending on how you cluster the data together

Taxonomy

science of classification; unified language classification system -a effective vehicle for communication among nurses and other health professionals

ICNP (International Classification for Nursing Practice)

standard terminology that provides a dictionary to describe and report nursing practice in a systematic way

Clinical Care Classification (CCC)

system that provides nursing diagnosis taxonomies for electronic medical record (EMR) systems -"Two interrelated taxonomies, the CCC of Nursing Diagnoses and Outcomes and the CCC of Nursing Interventions and Actions, that provide a standardized framework for documenting patient care in hospitals, home health agencies, ambulatory care clinics, and other healthcare settings"

etiology

the study of the causes of diseases

Objective data (signs)

what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination -the nurse's senses of sight, hearing, touch, and smell are used to collect this data