Basic Support- Nursing Process

Flashcards based on lecture notes covering the Nursing Process, Clinical Judgment, Hygiene, Safety, and Psychosocial Care.

What is clinical judgment in nursing?

Clinical judgment is using patient information to make a safe nursing decision.

What are the steps of the nursing process (ADPIE)?

ASSESS -> DIAGNOSE -> PLAN -> IMPLEMENT -> EVALUATE -> REASSESS.

In nursing assessment, how are subjective data and objective data distinguished?

Subjective data is what the patient says/feels, while objective data is what the nurse observes/measures.

What are the five types of nursing assessments?

1. Initial (comprehensive, establishes baseline) 2. Focused (specific problem) 3. Emergency (rapid assessment of life-threatening/unstable problem) 4. Ongoing (repeated monitoring for changes) 5. Time-lapsed (compares current status with previous baseline).

How does a nursing assessment differ from a medical assessment?

A medical assessment focuses on disease/pathology, whereas a nursing assessment focuses on the patient's response, function, needs, and ability to cope.

What must a nurse do if assessment data conflict or disagree?

STOP -> investigate -> gather more focused data -> validate.

What are the four steps of data analysis in the nursing process?

1. Recognize significant data (compare with normal/baseline) 2. Recognize patterns/clusters (connect related cues) 3. Identify strengths & problems 4. Reach conclusions.

What are the four possible conclusions after analyzing patient data?

1. No problem 2. Possible problem 3. Actual/potential nursing diagnosis 4. Clinical problem that isn't a nursing diagnosis.

What is the standard format for a problem-focused nursing diagnosis?

Problem + related to + as evidenced by (Example: Pain related to tissue injury as evidenced by patient reporting pain 6/10).

Why should 'as evidenced by' (AEB) not be used in a risk nursing diagnosis?

Because the problem has not happened yet (Example: Risk for infection related to open wound).

What are the five levels of Maslow's hierarchy used to prioritize nursing care?

1. Physiologic (oxygen, food, water, elimination, pain) 2. Safety 3. Love/belonging 4. Self-esteem 5. Self-actualization.

What does PPMP stand for in clinical decision-making?

Predict -> Prevent -> Manage -> Promote.

What is Quick Priority Assessment (QPA)?

Obtaining the most important information first when time is limited.

What criteria define a SMART patient outcome?

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

What are the four types of patient outcome domains?

1. Cognitive (KNOW -> knowledge) 2. Psychomotor (DO -> skill) 3. Affective (VALUE/FEEL -> attitudes/beliefs) 4. Physical (BODY -> physical change).

What is an indirect nursing intervention?

Care performed away from the patient but for the patient, such as coordinating with other healthcare professionals.

What two components must every evaluation statement include?

1. Met / Partially met / Not met 2. Evidence showing why.

What are the three types of reflection used to improve clinical judgment?

Reflection-in-action (NOW: What should I do right now?), Reflection-on-action (PAST: What happened? What could I have done differently?), and Reflection-for-action (FUTURE: What will I change next time?).

What are the six steps of the Gibbs Reflective Cycle?

Description -> Feelings -> Evaluation -> Analysis -> Conclusion -> Action Plan.

What are the 5 Rights of Delegation?

Right task, Right circumstance, Right person, Right directions/communication, and Right supervision/evaluation.

What are the six QSEN competencies for nursing care?

Patient-centered care, Safety, Teamwork/collaboration, Evidence-based practice, Informatics, and Quality improvement.

Which core questions match each step of the nursing process according to the HOSA-level framework?

1. What do I know? -> Assessment; 2. What does it mean? -> Analysis; 3. What is the nursing problem? -> Diagnosis; 4. What is most important? -> Prioritization; 5. What should happen? -> Outcome/Planning; 6. What will I do? -> Intervention/Implementation; 7. Did it work? -> Evaluation.

What components are included under hygiene care for physical and physiological support?

Bathing, showering and washing; Foot care; Hair care; Nail care; Perineal care; Shaving; Mouth and oral care; Denture care.

What are the four components of Safety and Clinical Maintenance?

Environmental Safety (keeping rooms clean and reducing fall hazards), Infection Control (hand hygiene and standard precautions), Wound Care (changing basic dressings and maintaining skin integrity), and Medication Administration (safely delivering oral or topical treatments).

What elements comprise Psychosocial Care in the provided notes?

Emotional Presence (listening and offering respectful communication) and Comfort Measures (managing pain and promoting restful sleep/comfort).