Nur 104: Eonc: Health Safety

Front 1

Nurses are expected to use ______________ _____________ to solve client problems and make better decisions.

Back 1

Critical thinking is the active process of skillfully analyzing and evaluating a client's need. Critical thinking, interrelated with problem solving and decision making, help to enhance the desired results.

Hint 1

Critical thinking.

Front 2

When nurses incorporate ______________ into their thinking, they are able to find unique solutions to unique problems.

Back 2

Certain situations may require the development of new ideas and/or products to implement a solution for a unique problem. A successful creative thinker must understand the problem and all facts and principles that apply to the client.

Hint 2

Creativity.

Front 3

_____________ ______________ is the application of a set of questions to a particular situation or idea to determine essential information and ideas and discard superfluous information and ideas.

Back 3

Both inductive and deductive reasoning are necessary for accurate critical analysis. Inductive reasoning is accomplished through discovering a set of facts or observations. Deductive reasoning brings the information to a more specific level. Both of these methods allow a nurse to question a client and obtain a critical analysis.

Hint 3

Critical analysis.

Front 4

The nursing process is a systematic, rational method of planning and providing _______________ nursing care.

Back 4

Individualized. There are very specific methods and processes for caring for a client. However, each client is an individual and will require individual assessment, evaluation, and planning to implement the appropriate care.

Hint 4

Individualized.

Front 5

In problem solving, the nurse obtains ________________ that clarifies the nature of the problem and suggests possible solutions.

Back 5

Once information is acquired on the client, the best solution can be chosen for their care. Other solutions are held in reserve as needed. What works for one client may not be the right solution for another client. Therefore, it is important for the nurse to determine the problem and then the solution on an individual basis.

Hint 5

Information.

Front 6

_______________ must be made whenever several mutually exclusive choices are available or when there is an option to act or not.

Back 6

The best actions to reach a desired goal require decision making. A nurse will have to make personal decisions about their daily life, as well as nursing decisions about their clients. In addition, nurses often assist clients in making decisions.

Hint 6

Decisions.

Front 7

The purpose of the nursing process is to identify a client's __________ status and actual or potential health care problems or needs, to establish plans to meet the identified needs and to deliver specific nursing interventions to meet those needs.

Back 7

The nursing process is a collection of five phases that provide a systematic and rational method of meeting the client's health needs. Those phases include assessing, diagnosing, planning, implementing, and evaluating.

Hint 7

Health.

Front 8

The purpose of ______________ is to establish a database about the client's response to health concerns or illness and the ability to manage health care needs.

Back 8

The initial phase of the nursing process, known as Assessing, is to obtain a health history, conduct a physical assessment, review the client's records, review nursing literature, and consult support persons and/or health professionals. Assessing will help the nurse determine the starting point for the health care of the client. Assessing will provide the ability to update, organize, validate, communicate, and document all data.

Hint 8

Assessing.

Front 9

Unless the client is too ill, young, or confused to communicate clearly, the client is the _____________ source of data.

Back 9

The client knows what they are feeling and can provide subjective data that no one else can offer.

Hint 9

Primary.

Front 10

______________ sources of data include family members, friends, and caregivers who know the client well and can supplement or verify information provided by the client.

Back 10

While the client should be the first source of data during assessing, support people can provide vital information and confirmation in extenuating circumstances. Nursing history should always specify if the data is obtained from a support person.

Hint 10

Secondary.

Front 11

Through the use of the senses, the nurse can _____________ a client as a method of collecting data.

Back 11

When assessing a client, the nurse will observe a client by using the senses. Through vision, smell, hearing, and touch, many aspects of a client's health can be determined.

Hint 11

Observe.

Front 12

A combination of directive and nondirective approaches is usually appropriate during the information-gathering ________________.

Back 12

It is necessary for the nurse to ask specific questions in a directive interview as part of the assessing phase. A nondirective approach includes a more relaxed conversation, with the client leading the conversation more. This allows a rapport to develop between the nurse and client and also informs the nurse of where the client's actual health concerns lie.

Hint 12

Interview.

Front 13

The physical ______________ is carried out systematically following the observation and interview of the client

Back 13

Once the nurse has collected data from the client observation and interview, it is necessary to secure actual physical data about the client's current condition. Some of this data may include height, weight, and vital signs.

Hint 13

Examination.

Front 14

All information acquired is ______________ in a written or computerized format.

Back 14

This nursing health history is vital to the continued care of the client. Once it is organized and recorded in the client's records, it will be referred to throughout their care.

Hint 14

Organized.

Front 15

All information gathered during the assessment phase must be _______________ to confirm that it is complete, factual, and accurate.

Back 15

Validation is the act of "double-checking" or verifying data to confirm that it is accurate and factual. During this process, the nurse can ensure that the assessment information is complete, that the data is all in agreement, and that nothing has been overlooked. She can also differentiate between cues and inferences in the observation and avoid jumping to conclusions and focusing in the wrong direction.

Hint 15

Validated.

Front 16

Accurate ________________ is essential and should include all data collected about the client's health status.

Back 16

All data should be documented in such a way as to prevent misinterpretation. Facts should be recorded accurately and not as interpreted by the nurse.

Hint 16

Documentation.

Front 17

International recognition of nursing diagnoses was accepted in the United States and Canada in 1982 with the formation of the North American Nursing Diagnosis Association or ____________.

Back 17

In 1973, the formal recognition and development of nursing diagnoses began. A need was seen to identify the nurses' roles in health care settings. The purpose of NANDA is to define, refine, and promote a classification system and set of principles of nursing diagnostic terminology for general use by professional nurses.

Hint 17

NANDA.

Front 18

Once the assessing of a client has been completed, ______________ will be used to interpret and analyze the data.

Back 18

All data that has been secured during the assessing phase will be used for diagnosing, the second phase of the nursing process. Comparison against standards and group data and identification of gaps and inconsistencies will assist during this process.

Hint 18

Diagnosing.

Front 19

________________ is a statement or conclusion regarding the nature of a phenomenon.

Back 19

Diagnosing refers to the reasoning process, whereas diagnosis is the actual conclusion drawn concerning a client's health condition.

Hint 19

Diagnosis.

Front 20

The causal relationship between a problem and its related or risk factors is known as ______________.

Back 20

Determining a health problem and risk factors associated with that problem help in diagnosing a client. Through analyzing the data, identifying health problems, and using the known etiology, a diagnosis can be reached.

Hint 20

Etiology

Front 21

A ________ diagnosis is a clinical judgment stating that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

Back 21

A risk diagnosis is used to describe a client's health status when other factors in their health cause the possibility of complications to be higher

Hint 21

Risk.

Front 22

A _____________ diagnosis is a diagnosis that is associated with a cluster of other diagnoses

Back 22

Other aspects of the client's health would be contributors to a syndrome diagnosis.

Hint 22

Syndrome.

Front 23

Nursing diagnoses differ from _____________ diagnoses in orientation, duration, and nursing focus.

Back 23

A nursing diagnosis is a statement of nursing judgment and refers to a condition that nurses are licensed to treat. A medical diagnosis is made by a physician and refers to a condition that only a physician can treat.

Hint 23

Medical

Front 24

Developing an individual care plan that specifies client goals and desired outcomes and related nursing interventions makes up the third phase of the nursing process, ______________.

Back 24

Once a client has been assessed and diagnosed, the most appropriate care plan must be developed for the individual. Priorities, goals, and strategies are planned under the consultation of other health professionals and this care plan is documented.

Hint 24

Planning

Front 25

In planning, the nurse refers to the client's assessment data and diagnostic statements for direction in formulating client goals and designing the nursing ________________ required to prevent, reduce, or eliminate the client's health problems.

Back 25

A nursing intervention is any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance the client's outcome.

Hint 25

Intervention

Front 26

A _______________ care plan is a formal plan that specifies the nursing care for groups of clients with common needs

Back 26

A standardized care plan is based on a plan used for all clients with the same diagnosis. These are preprinted guides that outline basic care procedures for certain diagnoses.

Hint 26

Standardized.

Front 27

When a care plan is tailored to meet the unique needs of a specific client that are not addressed in the standardized plan, this is called an _________________ care plan.

Back 27

Once a diagnosis has been determined, the standardized care plan is put into place. Then, the care plan is individualized to meet the specific needs of the client to address unusual problems or problems needing special attention

Hint 27

Individualized

Front 28

_______________ ___________ give nurses the authority to carry out specific actions under certain circumstances, often when a physician is not immediately available

Back 28

A written document in the form of a standing order may be included in the client's care plan to provide the nurse the authority to administer medication or obtain tests without the additional consent of the physician if certain situations arise.

Hint 28

Standing orders

Front 29

A ___________________ care plan is a standardized plan that outlines the care required for clients with common medical conditions

Back 29

Other health care providers are included in a multidisciplinary care plan for a client. It does not include detailed nursing activities, but sequences the daily care needed during the projected length of stay for the specific type of condition.

Hint 29

Multidisciplinary

Front 30

A taxonomy of nursing interventions referred to as the _____________ _______________ Classification (NIC) has been developed and consists of three levels: domains, classes, and interventions.

Back 30

The NIC is a classification of treatments that nurses perform. All NIC interventions assist nurses with determining the appropriate intervention for their client's health need. Nursing diagnoses are listed with offered suggestions for interventions. The nurse then selects the appropriate intervention based on their judgment and knowledge of the client.

Hint 30

Nursing Interventions

Front 31

Using NIC terminology, __________________ consists of doing and documenting the specific nursing actions needed to carry out the interventions or nursing orders

Back 31

The first three nursing process phases --- assessing, diagnosing, and planning --- provide the basis for the nursing actions performed during the fourth phase--implementing. Implementing is putting into action the plans for the individual client.

Hint 31

Implementing

Front 32

While implementing nursing orders, the nurse continues to _____________ the client at every contact, gathering data about the client's responses to the nursing activities and about any new problems that may develop.

Back 32

It is important to continue to be aware of the responses and changes that may occur while implementing the nursing orders. Being aware of the client through the implementation process allows the nurse to determine the effect of the treatment being used.

Hint 32

Reassess

Front 33

The ______________ skills, or intellectual skills, include problem solving, decision making, critical thinking, and creativity.

Back 33

Throughout the care of a patient, including the implementing of nursing orders, it is important to be aware of the client's response and use good cognitive skills to determine the effects.

Hint 33

Cognitive

Front 34

All of the activities, verbal and nonverbal, that people use when interacting directly with one another are called _________________ skills.

Back 34

Interacting with the client and with other members of the health care team will assure the best care for the client. The nurse must be able to understand and communicate with the client and others to achieve the most effective treatment.

Hint 34

Interpersonal.

Front 35

The "hands-on" skills needed in caring for a client, or the ______________ skills, include such skills as manipulating equipment, giving injections, bandaging, and moving, lifting or repositioning a client.

Back 35

Technical skills are also called tasks, procedures, or psychomotor skills. Knowledge and manual dexterity are necessary to fulfill this area of implementation.

Hint 35

Technical.

Front 36

After carrying out the nursing activities, the nurse completes the implementing phase by ______________ the interventions and client responses in the nursing progress notes.

Back 36

These notes are a part of the agency's permanent record for the client. Nursing activities should never be recorded in advance, but only after the actual care has been given. The nurse can keep a personal record of routine interventions on a worksheet and then transfer them to the client's record at the end of the shift. However, in some instances, it is important to record a nursing intervention immediately after it is implemented. (Such as medications, to prevent the client from receiving a duplicate dose.)

Hint 36

Recording

Front 37

Judging or appraising a client's status, or _______________, is a planned, ongoing, purposeful activity in which the client and health care professionals determine the client's progress toward achievement of goals and outcomes and the effectiveness of the nursing care plan

Back 37

Evaluation may be the final phase of the nursing process, but it is a continuous part of patient care. Conclusions drawn will determine whether the nursing interventions should be terminated, continued, or changed.

Hint 37

Evaluating.

Front 38

The last phase of the nursing process, evaluating, is based on all of the previous phases and overlaps with the _____________ phase.

Back 38

Knowing the diagnosis, the plan, and implementation of that plan, allow for a thorough evaluation. During the evaluation step, the nurse collects data for the purpose of comparing it to preselected goals and judging the effectiveness of the nursing care.

Hint 38

Assessing

Front 39

Using the clearly stated, precise, and measurable desired outcomes as a guide, the nurse _____________ data so that conclusions can be drawn about whether goals have been met.

Back 39

Both objective and subjective data are necessary and should be recorded to determine the client's status. This will include communication with and observance of the client and recording all measurable statistics

Hint 39

Collects

Front 40

It is important to ____________ the data collected with the outcomes to determine the effectiveness of the implemented care.

Back 40

If the nurse compares the data with the outcomes, a determination can be made whether the goal was met, the goal was partially met, or the goal was not met. An evaluation statement can then be recorded with a conclusion and supporting data on the client's record.

Hint 40

Compare

Front 41

Relating the nursing ______________ to the outcomes is necessary for an accurate evaluation.

Back 41

While a goal may or may not have been met in a client's care, it is important to determine if this was directly due to the nursing action or some other circumstance. It should never be assumed that a result was due only to a nursing action. Therefore, communication with the patient and review of the facts are vital

Hint 41

Activities

Front 42

Drawing _______________ about the problem status of a client will allow the nurse to adjust the nursing care plan as needed

Back 42

In reviewing whether goals have been met, partially met, or not met in a client's care plan, the nurse uses judgment about goal achievement to determine whether the care plan was effective in resolving, reducing, or preventing client problems.

Hint 42

Conclusions

Front 43

After drawing conclusions about the status of the client's problems, the nurse _____________ the care plan as indicated.

Back 43

. It may be necessary to continue, modify, or terminate the nursing care plan for a client based on the data, outcome, and conclusions reached. However, before making individual modifications, the nurse must first determine why the plan was or was not effective by reviewing the entire care plan and the steps involved in its development.

Hint 43

Modifies

Front 44

An ongoing, systematic process designed to evaluate and promote excellence in the health care provided to clients is called _____________ _______________ (QA)

Back 44

Evaluation of the care of a client is needed to assure the highest standards in all aspects. Quality assurance can refer to structure evaluation, which focuses on the setting in which the care is given; process evaluation, which focuses on how the care was given; and outcome evaluation, which focuses on demonstrable changes in the client's health status as a result of nursing care

Hint 44

Quality Assurance

Front 45

The nurse has a duty to maintain _________________ of all patient information

Back 45

The client's record is protected legally as a private record. The institution or agency is the rightful owner of the client's record and access to the record is restricted to health professionals involved in giving care to the client. However, the client has rights to the same records. To maintain confidentiality, care should be taken during computer usage and when faxing records.

Hint 45

Confidentiality