Nursing Process

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Nursing Process
2010-09-24 00:49:35
nursing process

exam 2 prep
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  1. Trial and error problem solvin
    Not effective, not acceptable, Can be dangerous
  2. Intuitive thinking problem solving
    "Going with your gut",
  3. Scientific Problem Solving
    systematic, uses scientific method, has steps, used in a controlled setting
  4. Methodical Reasoning problem solving
    Step by Step reasoning
  5. Why do you need a database?
    Establish baseline and use this to measure from. Identify strengths.
  6. What are the benefits of the nursing process?
    Individualized care= efficiency, Systematic, dynamic, collaborative= continuity of care.
  7. Define Critical Thinking
    A systematic way to form and shape thinking. Based on intellectual standards, comprehensive, disciplined.
  8. How do you develop technical skills?
    Practice until you feel/are competent and confident. Know new equipment, ask for help.
  9. Describe the Nursing Process
    Systematic, collects data through assessment, Patient centered- identifies goals, strengths & actual/potential problems. Outcome based- intervention to reach with help of patient.
  10. Define assessment
    • Collect
    • Validate
    • Communicate
  11. Types of nursing assessments
    • Initial: establish complete database for problem identification and planning.
    • Focused: Collect data on a specific problem.
    • Emergency: Identify life threatening problems.
    • Time-lapse: Compare current status to baseline.
  12. What is subjective data?
    The patient's report, not measurable
  13. What is objective data?
    Assessment, data collection that is measurable
  14. What is the primary source for information to patient history
    The patient (family secondary)
  15. Why is validation important?
    Keep free from error, bias, and misinterpretation.
  16. What is the diagnosis used for?
    Implementing nursing interventions related to symptoms
  17. What is the difference between a medical and a nursing diagnosis?
    • Medical: Identifies the disease.
    • Nursing: Focussed on unhealthy responses to health and illness.
  18. What are the types of nursing diagnosis?
    • Actual: Major defining factors.
    • Risk: make a clinical judgment the patient is vulnerable for.
    • Possible: Suspected problem that needs more data.
    • Wellness: Transition from one level of wellness to a higher level of wellness
  19. What is the purpose of outcomes (Goals)
    Establish priorities, identify outcome with patient, communicate plan of care with patient
  20. When is discharge planning identified?
    Concurrently, always
  21. What is implementation?
    Initiate interventions
  22. What is nurse-initiated interventions?
    Autonomous, clinical judgement, focused on patient outcomes.
  23. What is physician-initiated interventions
    Dependent nursing action to carry out a doctor's order. Nurses are still accountable
  24. What are collaborative interventions?
    inter-dependent nursing
  25. What is evaluation?
    Measuring accomplishment of outcome (goal), reassess if not met.
  26. Purpose of patient record
    Specific detailed information about patient that facilitates patient care. A financial/legal tool. Communication tool.
  27. What is focus charting?
    Focus on the patients concerns. DARE charting (used in ER)

    • Data
    • Assessment
    • Response
    • Evaluate
  28. What is the legal recourse for not documenting?
    If it's not charted, it didn't happen.
  29. What is Safety and Security (Maslow's 2nd level)
    Freedom from danger, harm, risk. A concern that underlines all nursing care.
  30. Techniques for fall prevention...
    Hand rails, proper lighting, clutter free environment, dispose broken equipment, low bed position, lock breaks on wheelchair & beds
  31. What are two types of restraints
    • Chemical
    • Physical/mechanical
  32. When are side rails x 4 not considered a restraint?
    Patient requests it (need to sign a consent form), seizure precautions
  33. Medication and Joint Commission Safety to prevent errors
    • Patient Identification x 2 identifiers
    • 3 checks
    • 7 rights
  34. What is the benefit to assist with patient bath?
    Assess skin integrity, develop rapport
  35. Phases of healing
    • Hemostasis
    • Inflammatory Process
    • Proliferation
    • Maturation Phase
  36. Hemostasis
    Start of blood clotting, 1st phase of wound healing
  37. Inflammatory Process
    Swelling. 2nd phase of wound healing
  38. Proliferation
    New tissue starts to form from the inside 3rd phase of wound healing
  39. Maturation Phase
    Scar tissue formation. Last phase of wound healing
  40. Factors in Pressure Ulcer Development
    • External pressure: Between a surface and the bone
    • Friction: Wrinkled sheets
    • Sheering: When patient is pulled instead of lifted up bed
  41. Pressure Ulcer Staging
    • Stage 1: red, does not blanch.
    • Stage 2: Shallow crater, partial thickness loss
    • Stage 3: Partial to full thickness, possible tunneling, cannot see bone, tendon
    • Stage 4: Full thickness, can see muscle, bone & tendon
  42. What are prevention measures for Pressure Ulcers
    • Reposition patient at least every 2 hours
    • Assess skin each shift
    • Float heels
  43. How long should heat/cold application be left on?
    20 min every 1 hour
  44. Purpose of heat therapy
    • Dilate vessels
    • reduce muscle tension
    • relieve pain
    • Attract oxygen & nutrients to the site
    • Increase leukocytes for inflammatory response.
  45. Purpose of cold therapy
    • Constricts blood vessels
    • Reduce edema & inflammation
    • Reduce muscle spasms
    • Control bleeding
    • Reduce pain
  46. Nurse role to promote body mechanics
    Assess/support patient to make lifestyle changes. Focus on regular exercise to slow aging process.
  47. Effects of immobility on the body
    • Cardiac: Increased cardiac workload.
    • Pulmonary: Decreased ventilation, increased secretions.
    • Muscle/skeletal: Weakness, atrophy, contractures.
    • GI: Constipation, poor digestion
    • GU: Stasis (slow flow), UTI, Stones
    • Skin: Breakdown
  48. What is assessed in a patient that has compromised mobility?
    • Muscle mass
    • Tone
    • Strength
    • Endurance
  49. Patient teaching in regards to immobility.
    Regular exercise to reduce adverse effects on the body.