Fundamentals of Nursing Practice

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Flashcards covering key vocabulary and concepts from the Fundamentals of Nursing Practice lecture notes.

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90 Terms

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Nursing as an Art

Requires skills like caring, communication, and teaching, developing a professional attitude anchored on ethics.

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Nursing as a Science

Requires scientific front based on knowledge applied systematically and critically in patient care.

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Nursing Process

A deliberate intellectual activity where nursing is performed systematically, using knowledge to assess, diagnose, plan, implement, and evaluate client needs.

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Nursing Process Characteristics

Goal-directed, systematic, dynamic, applicable to various groups, adaptable, interpersonal, and useful with any model.

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Purpose of Nursing

To provide a systemic methodology of nursing practice with emphasis on health promotion, maintenance, restoration, or enhancing peaceful death.

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1960s Scientific Era in Nursing

Stimulated the development of nursing with a focus on empirical knowledge, observable data, and analytical reasoning.

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Florence Nightingale's Impact

Her documentation helped shape modern nursing, which was previously based on apprenticeship learning and isolated principles.

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Nursing in the 1980s

Began integrating empirical, ethical, aesthetic, and personal patterns of knowing, moving away from over-reliance on empirical knowledge.

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Lydia Hall (1955)

First referred to nursing as a 'process'.

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ANA (1973)

Published the standard of practice including nursing diagnosis.

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NANDA (1991)

Made revisions to include outcome identification as part of the planning phase.

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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

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Assessment

Systematic and continuous collection, organization, validation, and documentation of data/information focusing on the client’s responses to health problems.

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Initial Nursing Assessment

Timely health agency entry, holistic database creation for future comparisons.

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Problem-Based Assessment

Focus on a specific problem.

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Emergency Assessment

Done during life-threatening situations.

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Time-Lapsed Reassessment

Follow-up check-up after a gap.

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Subjective Data

Symptoms; Covert data; According to the patient.

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Objective Data

Signs; Overt data; Observed or assessed by the nurse/ measurable or tested; involves the 5 senses.

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Primary Source of Data

Patient; Best source of data.

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Secondary Source of Data

Literature, Journals, Family, Medical personnel.

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Directive Interviewing

Questions are highly structured.

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Non-Directive Interviewing

Rapport building.

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Neutral Questions

Non-directive; Open-ended and answerable without direction or pressure.

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Leading Questions

Directive; Close-ended and directs the client’s answer.

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Validating Data

Confirming the data are accurate and factual, especially discrepancies between subjective and objective data or nurse's assumptions.

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Cues

Subjective or objective data that can be directly observed.

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Inferences

These are the nurse’s interpretations or conclusions made by the nurse

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Nursing Diagnosis

A clinical judgment about individual, family, or community responses to health problem processes.

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Actual Nursing Diagnosis

Problem present at the time the statement was made.

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High-Risk Nursing Diagnosis

A diagnosis that a patient is more vulnerable or susceptible compared with others in the same situation.

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Possible Nursing Diagnosis

Evidence of a health problem but the causes are not fully understood

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Wellness Nursing Diagnosis

A positive statement.

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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

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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.

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Defining Characteristics

Cluster of existing signs and symptoms indicates actual diagnosis.

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Analysis

Separation into components (deductive reasoning).

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Synthesis

Putting together of parts into whole (inductive reasoning).

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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.

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Nursing Intervention

Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.

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Initial Planning

Developed by the nurse who performs the admission assessment, using intuition from seeing the client's body language.

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Ongoing Planning

Individualizing the initial care plan based on new information and client responses, adapting to daily changes in health status.

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Discharge Planning

Crucial part of care, starting at first client contact, anticipating needs after discharge, considering the trend toward shorter hospital stays.

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Formal Nursing Care Plan

Written or computerized guide organizing client care information, ensuring continuity of care.

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Standardized Care Plan

Formal plan specifying nursing care for groups of clients with common needs, like myocardial infarction.

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Individualized Care Plan

Tailored to meet the unique needs of a specific client, addressing factors not addressed by standardized plans.

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Priority Setting

The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.

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NOC

Nursing Outcomes Classification: a taxonomy for describing client outcomes that respond to nursing interventions.

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Goals/Desired Outcomes

Describe observable client responses, provide direction for interventions, and serve as criteria for evaluating progress.

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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.

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Direct Care

Intervention performed through interaction with the client.

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Indirect Care

Intervention performed away from but on behalf of the client, such as interdisciplinary collaboration or management of the care environment.

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Independent Inteventions

Activities that nurses are licensed to initiate on the basis of their knowledge and skills.

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Dependent Interventions

Activities carried out under the primary care provider’s orders or supervision, or according to specified routines.

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Collaborative Interventions

Actions the nurse carries out in collaboration with other health team members.

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NIC

A taxonomy of nursing interventions.

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Implementation

The action phase of the nursing process in which the nurse executes or delegates nursing interventions, concluding by recording actions and client responses.

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Cognitive Skills

Problem-solving, decision making, critical thinking, clinical reasoning, and creativity.

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Interpersonal Skills

Activities used when interacting directly with others; therapeutic communication, rapport building, collaboration, respect.

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Technical Skills

Purposeful 'hands-on' skills like manipulating equipment, giving injections, bandaging, moving, lifting, and repositioning clients.

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Direct Care

Actions that are performed by the nurse when interacting with client.

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Indirect Care

An intervention delegated by the nurse to another provider or performed away from but on behalf of the client.

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Evaluation

Planned, ongoing, purposeful activity where clients and healthcare professionals determine progress toward goals/outcomes and effectiveness of the nursing care plan

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QA Program

Ongoing, systematic process designed to evaluate and promote excellence in the healthcare provided to clients.

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Audit

Refers to the examination or review of records.

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Retrospective Audit

Evaluation of a client’s record after discharge from an agency. Retrospective means “relating to past events.”

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Concurrent Audit

Is the evaluation of a client’s healthcare while the client is still receiving care from the agency.

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Science of Assessment

Includes collection, organization, validation and documentation of client's data.

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Subjective Data

Considered the cues to action for nurses as it implies the felt need of the client.

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Objective Data

Considered the cues to action for nurses as it implies what is seen or observed.

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Science of Nursing Diagnosis

Suggests that there is any process to come up with a nursing diagnosis.

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Science of Planning

The nursing science of planning ensures that nurses create goals and objectives to prevent, reduce or resolve identified problems.

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Science of Implementation

The nursing science of implementation includes the process of carrying out the planned nursing care intervention.

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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.

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Health

A state of complete physical, psychological and social well - being and not merely the absence of disease or infirmity

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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

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Illness

A highly personal state.

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Disease

More on objective (distinguished through lab tests).

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Acute

Characterized by symptoms of relatively short duration (less than 6 mos)

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Chronic

Usually, slow onset and last for 6 mos or longer.

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Primary Level

Focused on health promotion and disease prevention protection against specific health problems

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Secondary Level

Focuses on early identification and promip intervention for health problems

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Tertiary Level

Focuses on restoration, rehabilitation, and paliative care.

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Smith’s Four Clinical Models of Health

Clinical Model, Role Performance Model, Adaptive Role Model, Eudaimonistic Model.

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Health Belief Models

Perceived Severity, Perceived Susceptibility, Perceived Benefits, Perceived Barriers

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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.

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Health Beliefs

Concepts about health that an individual believes are true such beliefs may or may not be founded on fact.

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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.

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Internal Variables

Biologic, Psychological, and cognitive dimensions.

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External Variables

Affecting health include the physical environment, standards of living, family and cultural beliefs, and social support networks.