Nursing Process and Care Planning

Flashcards covering etiology in nursing diagnoses, data types, planning/outcomes, interventions, evaluation, communication, discharge planning, and related concepts from the lecture notes.

What is the purpose of identifying the etiology in a nursing diagnosis?

To determine what is causing the problem, ensuring the cause is nursing-related rather than a medical diagnosis.

What is an important rule when selecting an etiology for a nursing diagnosis?

Do not use a medical diagnosis as the etiology; focus on nursing-related factors.

Define subjective data in a nursing assessment.

Information reported by the patient that cannot be measured directly (e.g., symptoms, feelings).

Define objective data in a nursing assessment.

Observable, measurable data obtained through examination and tests (e.g., heart rate, breath sounds).

What are SMART outcomes in nursing planning?

Specific, Measurable, Attainable, Realistic, and Time-based.

Give an example of a singular-focused patient goal.

A goal that targets only one outcome at a time (e.g., sit up in a chair 30 minutes, 3x/day).

Differentiate direct vs indirect nursing interventions.

Direct interventions are performed with the patient (e.g., turning, ambulation). Indirect interventions are performed away from the patient (e.g., care coordination, discharge planning).

What is the difference between physician-initiated and collaborative interventions?

Physician-initiated interventions are provider orders; collaborative interventions involve other team members (PT, OT, etc.) with or without direct orders.

What are nursing-initiated interventions? Give two examples.

Interventions a nurse can initiate without a provider order based on clinical judgment (e.g., turning every two hours; using incentive spirometer).

What is the purpose of discharge planning in acute care?

Starts on admission to reduce readmission (e.g., within 30 days for heart failure) and ensure patient education and follow-up.

What is meant by risk for injury as a nursing diagnosis?

A broad risk Dx without current objective/subjective data; requires ongoing monitoring and prevention strategies.

List the five rights of medication administration.

Right patient, right drug/dose, right route, right time, and right documentation.

What are the steps to ensure safe medication administration with MAR?

Compare MAR to the doctor's order, verify patient identity, check dose, route, time, and contraindications before administration.

What is SBAR and when is it used?

Situation, Background, Assessment, Recommendation; a communication framework used among healthcare providers.

What is the purpose of standardized care plans?

Predefined plans for common conditions that can be individualized to the patient.

Why is incentive spirometry used after surgery?

To promote lung expansion and prevent pneumonia by preventing atelectasis.

Why is planning stage of the nursing process important?

To prioritize problems, identify expected outcomes, select evidence-based interventions, and communicate the plan.

What are the four types of outcomes in evaluation and what do they mean?

Psychomotor (actions), Cognitive (knowledge/teach-back), Affective (attitudes/ coping), Physiological (vital signs/physical status).

What is the difference between 'terminate' and 'modify' a care plan?

Terminate when outcomes are met; modify or continue if partially met or not met.

What should you consider during ongoing planning in response to a patient’s status change?

Reassess, collect new data, update plan, and modify interventions as needed.

What is the role of family involvement in care planning and discharge?

Family involvement is crucial; involve them with patient preferences and post-discharge planning.

What is meant by 'care bundles' in nursing interventions?

A set of evidence-based practices grouped for a condition or procedure (e.g., ortho care bundles).

What is the role of the teach-back method in patient education?

A cognitive evaluation method where the patient explains back what they learned to confirm understanding.

Why is documentation essential in nursing practice?

It provides evidence of care, protects the patient, and is used in legal contexts.