Test 1

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Test 1
2011-09-29 15:48:42
Module 1C

Module 1 C
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  1. in 1960 theorist described nursing as
    a distinct entity among the healthcare professions and also delineated specific steps in a process approach to nursing ADPIE
  2. ADPIE
    • assessment
    • diagnosis
    • outcome indentification & planning
    • implementation
    • evaluation
  3. ANA definition for the scope and standards of nursing practice
    nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals,, families, communitites and populations
  4. the nursing process is
    a systematic method that directs the nurse and the patient, as together they accomplish the 5 steps (adpie)
  5. characteristics of the nursing process are:
    • systematic
    • dynamic
    • interpersonal
    • outcome oriented
    • &
    • universally applicable
  6. problem solving
    • is a basic life skill:
    • identifying a problem and then taking the steps to resolve it
  7. therapeutic communicaton
    • ADPIE
    • assessing
    • diagnosing
    • outcome identification & planning
    • implementing
    • evaluating
    • documenting communication
    • hand-off communication SBAR
    • S ituation
    • B ackground
    • A ssessment
    • R ecomendations
  8. characteristics of data
    • when collecting and recording data nurses should be
    • purposeful
    • complete
    • accurate
    • factual
    • relevant
  9. 3 methods of data collection
    observation--the conscious and deliberate use of the five senses to gather data.

    interview--is a planned communication

    physical assessment--the examination of the patient for objective data
  10. components of nursing history
    • profile-name,age,sex etc
    • reason for seeking healthcare
    • normal health habits and patterns
    • cultural considerations -relation to diet,decision making
    • current state of health
    • current meds, allergies & immunizations
    • perception of health status
    • developmental, family,environment & psychosocial history
    • patient and familys expectations
    • patient and familys ability and willingness to follow care planned
    • patients and familys educational needs
    • whether or not an advance directives exists
    • patients personal resources (strenghts) and deficits
    • patients potential for injury
  11. types of data
    • subjective
    • and
    • objective
  12. subjective data
    information perceived only by the affected person, these data cannot be verfied or perceived by another
  13. objective data
    are observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
  14. validation
    is the process of confirming or verifying
  15. data must be validated when
    • there are discrepancies
    • and
    • when they lack objectivity
  16. cue
    denotes significant data or data that influence an analysis
  17. process of analyzing a patients data
    • recognizing significant data
    • recognizing patterns and clusters
    • indentifying strengths and problems
    • identifying potential complications
    • reaching conclusions
    • partnering with patient
  18. standard
    is a norm, or a generally accepted rule in the same class or category
  19. data cluster
    is a grouping of patient data or cues that points to the existence of a patient health problem
  20. nursing diagnosis should always be derived from
    a cluster of significant data
  21. reaching conclusions nurses reach one of 4 possible basic conclusions
    • no problem
    • possible problem
    • actual or potential nursing diagnosis
    • clinical problem other than nursing diagnosis
  22. no problem
    • no response indicated
    • reinforce patients health habits and patterns
    • initiate health promotion activities to prevent disease or illness or to promote higher level of wellness
    • wellness diagnosis might be indicated
  23. possible probelm
    collect more data to confirm or disprove suspected probloem
  24. actual or potential nursing diagnosis
    • begin planning, implementing, and evaluating care designed to prevent, reduce, or resolve problem
    • if unable to treat problem b/c patient denies and refuses treatment, make patient aware of possible outcomes for this stance
  25. clinical problem other tha nursing diagnosis
    • consult with approriate healthcare professional and work collaboratively on problem
    • refer to medicine or other services
  26. medical diagnosis vs nursing diagnosis
    medical diagnosis: identify diseases.pysician diagnoses and directs for treatment. remains the same as long as the disease remains

    nursing diagnosis: focus on unhealthy response to health and illness, can change from day to day
  27. NANDA describe 5 types of nursing diagnosis
    • -actual
    • -risk
    • -possible
    • -wellness
    • -syndrome
  28. actual nursing diagnosis
    represent a problem that has been validated by the presence of major defining characteristics
  29. risk nursing diagnosis
    are clinical judgements that an individual, family, or community is more vulnerable to develope the problem
  30. possible nursing diagnosis
    are statements describing a suspected problem for which additional data are needed
  31. wellness diagnosis
    are clinical judgements about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness
  32. syndrome nursing diagnosis
    comprise a cluster of actual or risk nursing dianoses that are predicted to be present b/c of a certain event or situation
  33. parts of a nursing diagnosis statement
    • problem
    • etiology
    • defining characteristics
  34. problem part of the nursing diagnosis statement
    describes the health state or health problem of the patient as clearly and concisely as possible
  35. the etioly part of a nursing diagnosis statement
    identifies the physiologic, psychologincal, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor
  36. the "defining characteristics" part of a nursing diagnosis statement
    is the subjective or objective datat that signal the existence of the actual or potential health problem.
  37. anticipatory
    realize beforehand, foresee
  38. compromised
    damaged, made vulnerable
  39. decreased
    lessened in size, amount or degree
  40. deficient
    insufficient, inadequate
  41. delayed
    late, slow or postponed
  42. disabled
    limited, handicapped
  43. disorganized
    not properly arranged
  44. disproportionate
    too large or too small in comparison with the norm
  45. disturbed
    agitated,interrupted, interfered with
  46. dysfunctional
    not operating normally
  47. effective
    producing the inteded or desired result
  48. excessive
    greater than necessary or desirable
  49. imbalanced
    out of proportion or balance
  50. imparied
    damaged or weakend
  51. ineffective
    not producing the inteded or desired effect
  52. interrupted
    having its continuity broken
  53. low
    below norm
  54. organized
    properly arranged or controlled
  55. perceived
    observed through the senses
  56. readiness
    in a suitable state for an activity or situation
  57. situational
    related to a particular circumstance
  58. cue
    significant info that is helpful in making decisions
  59. collaborative problems
    actual or potential health problems that may occer from complications from disease
  60. data
  61. diagnosing
    anyalysis of a patient
  62. etiology
    study of the cause of disease
  63. evaluate
    to rate or assess
  64. implement
    to carry out the plan of care
  65. medical diagnosis
    statement about a specific disease process using terminology from a well developed classification
  66. nursing diagnosis
    actual or potential health problem that a nursing intervention can prevent
  67. nursing history
    assessment of the patient by interviewing the patient
  68. nursing process plan
    • ADPIE
    • assessing
    • diagnosing
    • organizing and planning
    • implementing
    • evaluating
  69. objective data
    percievable by the senses
  70. plan of nursing care
    written guide that directs the efforts of the nursing team to meet health goals
  71. protocol
    written plan that describes nurses activities
  72. standards of critical thinking
    clear, concise, specific, accurate, relevant, plausible, consistent
  73. subjective data
    info perceived only by the affected patient