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Flashcards covering key vocabulary and concepts from the Fundamentals of Nursing Practice lecture notes.
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Nursing as an Art
Requires skills like caring, communication, and teaching, developing a professional attitude anchored on ethics.
Nursing as a Science
Requires scientific front based on knowledge applied systematically and critically in patient care.
Nursing Process
A deliberate intellectual activity where nursing is performed systematically, using knowledge to assess, diagnose, plan, implement, and evaluate client needs.
Nursing Process Characteristics
Goal-directed, systematic, dynamic, applicable to various groups, adaptable, interpersonal, and useful with any model.
Purpose of Nursing
To provide a systemic methodology of nursing practice with emphasis on health promotion, maintenance, restoration, or enhancing peaceful death.
1960s Scientific Era in Nursing
Stimulated the development of nursing with a focus on empirical knowledge, observable data, and analytical reasoning.
Florence Nightingale's Impact
Her documentation helped shape modern nursing, which was previously based on apprenticeship learning and isolated principles.
Nursing in the 1980s
Began integrating empirical, ethical, aesthetic, and personal patterns of knowing, moving away from over-reliance on empirical knowledge.
Lydia Hall (1955)
First referred to nursing as a 'process'.
ANA (1973)
Published the standard of practice including nursing diagnosis.
NANDA (1991)
Made revisions to include outcome identification as part of the planning phase.
Purpose of NCP
Identify client’s health status and actual or potential healthcare problems of needs Establish plans to meet needs Deliver specific interventions Unifies Stanadards and direct nursing care
Assessment
Systematic and continuous collection, organization, validation, and documentation of data/information focusing on the client’s responses to health problems.
Initial Nursing Assessment
Timely health agency entry, holistic database creation for future comparisons.
Problem-Based Assessment
Focus on a specific problem.
Emergency Assessment
Done during life-threatening situations.
Time-Lapsed Reassessment
Follow-up check-up after a gap.
Subjective Data
Symptoms; Covert data; According to the patient.
Objective Data
Signs; Overt data; Observed or assessed by the nurse/ measurable or tested; involves the 5 senses.
Primary Source of Data
Patient; Best source of data.
Secondary Source of Data
Literature, Journals, Family, Medical personnel.
Directive Interviewing
Questions are highly structured.
Non-Directive Interviewing
Rapport building.
Neutral Questions
Non-directive; Open-ended and answerable without direction or pressure.
Leading Questions
Directive; Close-ended and directs the client’s answer.
Validating Data
Confirming the data are accurate and factual, especially discrepancies between subjective and objective data or nurse's assumptions.
Cues
Subjective or objective data that can be directly observed.
Inferences
These are the nurse’s interpretations or conclusions made by the nurse
Nursing Diagnosis
A clinical judgment about individual, family, or community responses to health problem processes.
Actual Nursing Diagnosis
Problem present at the time the statement was made.
High-Risk Nursing Diagnosis
A diagnosis that a patient is more vulnerable or susceptible compared with others in the same situation.
Possible Nursing Diagnosis
Evidence of a health problem but the causes are not fully understood
Wellness Nursing Diagnosis
A positive statement.
Problem (Diagnostic label)
Describes the client’s health problem or response May require specification Qualifiers added to give additional meaning o Such as deficient, impaired, decreased. ineffective, and compromised
Etiology (Related factors)
Identifies one or more probable causes of the health problem Gives direction to the required nursing therapy Enables the nurse to individualize the client’s care Etiology is based on client’s cues.
Defining Characteristics
Cluster of existing signs and symptoms indicates actual diagnosis.
Analysis
Separation into components (deductive reasoning).
Synthesis
Putting together of parts into whole (inductive reasoning).
Planning Phase of Nursing Process
Nurse refers to assessment data and diagnostic statements, formulates goals, and designs nursing interventions to prevent, reduce, or eliminate health problems.
Nursing Intervention
Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.
Initial Planning
Developed by the nurse who performs the admission assessment, using intuition from seeing the client's body language.
Ongoing Planning
Individualizing the initial care plan based on new information and client responses, adapting to daily changes in health status.
Discharge Planning
Crucial part of care, starting at first client contact, anticipating needs after discharge, considering the trend toward shorter hospital stays.
Formal Nursing Care Plan
Written or computerized guide organizing client care information, ensuring continuity of care.
Standardized Care Plan
Formal plan specifying nursing care for groups of clients with common needs, like myocardial infarction.
Individualized Care Plan
Tailored to meet the unique needs of a specific client, addressing factors not addressed by standardized plans.
Priority Setting
The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.
NOC
Nursing Outcomes Classification: a taxonomy for describing client outcomes that respond to nursing interventions.
Goals/Desired Outcomes
Describe observable client responses, provide direction for interventions, and serve as criteria for evaluating progress.
Nursing Interventions and Activities
Actions a nurse performs to achieve client goals/desired outcomes, focusing on eliminating or reducing the etiology of the nursing diagnosis.
Direct Care
Intervention performed through interaction with the client.
Indirect Care
Intervention performed away from but on behalf of the client, such as interdisciplinary collaboration or management of the care environment.
Independent Inteventions
Activities that nurses are licensed to initiate on the basis of their knowledge and skills.
Dependent Interventions
Activities carried out under the primary care provider’s orders or supervision, or according to specified routines.
Collaborative Interventions
Actions the nurse carries out in collaboration with other health team members.
NIC
A taxonomy of nursing interventions.
Implementation
The action phase of the nursing process in which the nurse executes or delegates nursing interventions, concluding by recording actions and client responses.
Cognitive Skills
Problem-solving, decision making, critical thinking, clinical reasoning, and creativity.
Interpersonal Skills
Activities used when interacting directly with others; therapeutic communication, rapport building, collaboration, respect.
Technical Skills
Purposeful 'hands-on' skills like manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients.
Direct Care
Actions that are performed by the nurse when interacting with client.
Indirect Care
An intervention delegated by the nurse to another provider or performed away from but on behalf of the client.
Evaluation
Planned, ongoing, purposeful activity where clients and healthcare professionals determine progress toward goals/outcomes and effectiveness of the nursing care plan
QA Program
Ongoing, systematic process designed to evaluate and promote excellence in the healthcare provided to clients.
Audit
Refers to the examination or review of records.
Retrospective Audit
Evaluation of a client’s record after discharge from an agency. Retrospective means “relating to past events.”
Concurrent Audit
Is the evaluation of a client’s healthcare while the client is still receiving care from the agency.
Science of Assessment
Includes collection, organization, validation and documentation of client's data.
Subjective Data
Considered the cues to action for nurses as it implies the felt need of the client.
Objective Data
Considered the cues to action for nurses as it implies what is seen or observed.
Science of Nursing Diagnosis
Suggests that there is any process to come up with a nursing diagnosis.
Science of Planning
The nursing science of planning ensures that nurses create goals and objectives to prevent, reduce or resolve identified problems.
Science of Implementation
The nursing science of implementation includes the process of carrying out the planned nursing care intervention.
Science of Evaluation
The science of evaluation of nursing care measures the degree to which nursing goals and objectives are met. Is also a means to identify which factors influences the success or struggles of goal achievement.
Health
A state of complete physical, psychological and social well - being and not merely the absence of disease or infirmity
Wellness
The optimal state of health that includes the realization of health and fulfillment of one’s role expectations in the family, community and society
Illness
A highly personal state.
Disease
More on objective (distinguished through lab tests).
Acute
Characterized by symptoms of relatively short duration (less than 6 mos)
Chronic
Usually, slow onset and last for 6 mos or longer.
Primary Level
Focused on health promotion and disease prevention protection against specific health problems
Secondary Level
Focuses on early identification and promip intervention for health problems
Tertiary Level
Focuses on restoration, rehabilitation, and paliative care.
Smith’s Four Clinical Models of Health
Clinical Model, Role Performance Model, Adaptive Role Model, Eudaimonistic Model.
Health Belief Models
Perceived Severity, Perceived Susceptibility, Perceived Benefits, Perceived Barriers
Health Status
State of health of an individual at a given time a report of health status may include anxiety, depression, or acute illness that describes individual's problems in general.
Health Beliefs
Concepts about health that an individual believes are true such beliefs may or may not be founded on fact.
Health Behaviors
Actions people take to understand their health, maintain an optimal state of health, prevent illness and injury and reach their maximum physical and mental poteintal.
Internal Variables
Biologic, Psychological, and cognitive dimensions.
External Variables
Affecting health include the physical environment, standards of living, family and cultural beliefs, and social support networks.