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54 Cards in this Set
- Front
- Back
The Nursing Process |
Is a way of thinking and acting based on the scientific method(step by step process used by scientist to solve problems) |
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Scientific Method |
Step by step process used by a scientist to solve problems |
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The Five Components of the Nursing Process? |
Assessment Nursing Diagnosis Planning Implementation Evaluation |
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NFLPN |
National Federation of Licensed Practical Nurse |
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Clinical Reasoning |
Skills that result in solid Clinical Judgement |
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What does critical mean? |
Means requiring careful judgment |
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Thinking term used in (Critical Thinking) means |
Thinking means to reason |
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The Term "Critical Thinking" is defined as? |
Directed, purposeful, mental activity by which you evaluate ideas, construct plans, and determine desired outcomes. |
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Critical Thinking inside the clinical setting? |
is called clinical reasoning, which is necessary to make reliable observations regarding health status and to draw sound conclusion from the data obtained |
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Clinical Judgment |
is the outcome of clinical reasoning |
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Decision making |
is choosing the best actions to meet a desired goal and is part of critical thinking |
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EBP |
Evidence based practice |
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KSA |
Knowledge, Skills, Attitudes |
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Assessments (Data Collection) |
Collecting, organizing, documentation, and validating data about a patients health status. Assessment data is gathered from the patient, family, doctor, diagnostic tests. |
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Nurse Diagnosis |
Assessment data is sorted and analyzed so that specific, actual, and potential health problems are identified. Specific nursing diagnosis are chosen for the patients care plan. |
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Planning |
A series of steps the nurse and the patient set priorities and goals to eliminate or diminish the identified problems. |
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Implementation |
Carrying out the nursing interventions in a systematic way. The patients response to the care given is documented |
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Evaluation |
Assessing the patients response to the nursing interventions. Compared with the expected outcomes to determine whether they have been achieved. |
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Priority |
More and important then something else at the time |
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Prioritizing includes? |
placing nursing diagnoses or nursing interventions in order of importance |
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The Three Methods of Data Collection Can Be? |
Structured format from the 11 functional health patterns Focused Assessment-Concerned with one specific problem Maslows Hierarchy of basic needs-assess every area |
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Interview |
conversation in which facts are obtained about a patient |
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Subjective Data |
Data obtained from the patient verbally |
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Objective Data |
Information obtained through the senses and hands on physical examination, vital signs, diagnostic test are examples |
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Interview |
focused on gathering information/data and is not a social interaction |
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Interviews are assessed in such a way? |
The opening= Rapport The Body=necessary questions are obtained The Closing= finish and ask if the patient has any questions |
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Inspection |
Portion of the physical examination= Looking |
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Auscultation |
Listening |
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Palpation |
touching |
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Percussion |
thumping |
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Long Term Care Facility ADL's |
Activities of Daily Living In which a patient will need assessment |
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Cues |
Pieces of data or information that influence decisions such as signs and symptoms |
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Nursing Diagnosis |
Statement indicates the patients actual health status or the risk of a problem developing, the causative or related factors, and specific characteristics (Signs and Symptoms) |
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NANDA-I |
National American Nursing Diagnosis Association-International |
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Etiological Factors |
the cause of the problem |
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Defining Characteristics |
Signs and Symptoms that must be present for a particular nursing diagnosis to be appropriate for the patient |
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Signs |
Abnormalities that can be verified by repeat examination and are objective data |
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Symptoms |
Are factors the patient has said are occurring that cannot be verified by examination. i.e. symptoms are subjective data |
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Nursing diagnosis |
defines the patients response to illness |
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Medical Diagnosis |
Labels an illness |
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r/t means |
related to |
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Goals |
broad idea of what is to be achieved through the nursing intervention |
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Short term goals |
are those that are achieved in 7-10 days or before discharge |
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Long term goals |
often relate to rehabilitation |
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Expected outcomes |
Derived from goals, specific statement regarding the goal the patient is expected to achieve as a result of nursing intervention |
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Expected Outcome |
should be realistic and attainable and should have a defined time line, collaboration with the patient regarding the expected outcomes is important |
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Time-flexible |
can be done anytime |
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Time-fixed |
must be done at a set time |
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Independent Nursing Action |
does not require a physicians order |
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Dependent Nursing Action |
requires a doctors order |
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Interdependent Action |
Collaborating with health professionals, assisting with physical therapy by helping the patient exercise |
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Remember |
The nurse performs any invasive procedure and any sterile procedure |
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Remember |
Nurses notes must indicate that the nursing care plan has been carried out, if not documented action is considered not done |
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Outcome-based quality improvement QBQI |
Improvement of the quality of performance |