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491 Terms
What are the 5 phases of the nursing process?
Assessment → Diagnosis → Planning → Implementation → Evaluation (ADPIE).
What is clinical decision making?
A critical-thinking process for choosing the best actions to meet a desired goal.
What 3 things go into clinical decision making?
Nurse's clinical skills/expertise + client preferences + evidence.
What is clinical judgment?
The thought process (clinical reasoning) that allows a healthcare provider to reach a conclusion based on objective and subjective patient information.
What are salient cues?
Significant data that indicate a positive or negative change in a client's health status or differ from expected norms.
What is assessment?
Systematic, continuous collection of data focused on the client's response to a health problem.
Does assessment happen only at the beginning of the nursing process?
No. Data collection continues throughout all phases of the nursing process.
What is subjective data?
Information reported by the client or family—what the patient says/experiences.
What is objective data?
Data obtained through physical examination/observation—what you can see, hear, measure, or observe.
What is the primary source of data?
The client/patient.
What is a secondary source of data?
Any source other than the client, such as family or other information sources.
What can nurses use to organize assessment data?
Nursing models such as Gordon's 11 functional health patterns, Roy's adaptation model, and Maslow's hierarchy of needs, or body systems.
What happens during the diagnosis phase?
The nurse clusters assessment data, identifies problems, and gives the problem a name.
What is a nursing diagnosis?
A statement of nursing judgment about a patient's human response to a health condition.
What is a medical diagnosis?
A disease-focused diagnosis made by a physician, APRN, or PA.
What type of diagnosis is 'Pneumonia'?
Medical diagnosis.
What type of diagnosis is 'Acute pain related to tissue injury'?
Nursing diagnosis.
What does a nursing diagnosis focus on?
The patient's response to the health condition—not the disease itself.
What are the 4 types of nursing diagnoses?
Actual, Risk, Health promotion, Syndrome.
What is an actual nursing diagnosis?
A problem-focused diagnosis where the problem is currently present.
What is a risk nursing diagnosis?
The problem doesn't currently exist, but the patient has risk factors for developing it.
What is a health promotion diagnosis?
A diagnosis indicating readiness to improve.
What is a syndrome diagnosis?
A cluster of nursing diagnoses that can occur together.
What are the components of a nursing diagnosis?
Diagnostic label, Etiology, Defining characteristics.
What is the diagnostic label?
The problem, approved by NANDA.
What is the etiology?
The related factors/risk factors—probable causes of the health problem.
What are defining characteristics?
A cluster of signs and symptoms indicating the presence of a particular diagnosis.
What happens during planning?
The nurse develops client goals and determines appropriate nursing interventions.
Who must be involved in planning?
The client. Goals must be client-centered.
What is the purpose of goals?
They provide criteria for evaluating the patient's progress.
What does SMART stand for?
Specific, Measurable, Attainable, Relevant, Time-limited.
Which is a better goal: 'Patient will have less pain.' or 'Patient will report pain of 2/10 or lower by the end of shift.'?
The second. It's measurable and time-limited.
What is implementation?
The action phase of the nursing process.
What happens during implementation?
Identify the best priority intervention and implement the intervention.
What are nursing interventions?
Actions the nurse performs to achieve goals.
What is an independent nursing intervention?
An intervention the nurse is licensed to initiate independently.
What is a collaborative intervention?
An intervention performed with other members of the healthcare team.
What is a dependent intervention?
An intervention carried out under a physician's order/supervision.
What should nursing interventions be based on?
Current best nursing research evidence, client values/beliefs/culture, and standards of care/other therapies.
What is evaluation?
The last phase of the nursing process where the nurse determines the client's progress toward achieving goals and the effectiveness of the care plan.
What are the 3 possible evaluation conclusions?
Goal met, goal partially met, goal not met.
What should an evaluation statement contain?
Date/time, whether goal was met, partially met, or not met, and a supporting statement describing the patient's results.
What happens if a goal is not met?
Reassess and potentially adapt/reprioritize the nursing diagnosis, revise goals, and redesign interventions.
What does 'priority' mean?
Giving attention to something before competing alternatives.
Why do nurses prioritize care?
To manage time and establish the order of care, especially when caring for multiple patients.
What are the main tools for prioritization?
ABCs + Maslow's hierarchy + client preferences + law.
What does ABC stand for?
Airway → Breathing → Circulation.
Which is usually the priority: a breathing problem or a psychosocial problem?
Breathing problem.
What type of cues indicate a potentially serious change in health status?
Salient/significant cues.
According to Maslow, what is the FIRST priority?
Physiological needs.
After physiological needs, what should you look for?
Safety needs, followed by psychosocial needs if physiological and safety aren't options.
What is a high-priority situation?
A life-threatening situation that must be addressed first.
What is a medium-priority situation?
A problem that can cause unhealthy physical or emotional consequences but isn't life-threatening.
What is a low-priority situation?
Something that can be delayed/resolved easily without causing dysfunction and may be delegated.
What is the urgency factor?
How much time can pass before negative consequences occur.
If two patients both need care, what makes one a higher priority?
The patient whose condition has greater urgency/acuity and whose delay could result in more serious consequences.
What is the nurse's responsibility when delegating?
The task must be within the delegatee's scope of practice, and the RN evaluates whether it was completed.
Who may nurses delegate appropriate tasks to?
LPNs and UAPs, as appropriate to their scope.
What is a major safety principle during nursing care?
Do no harm. Don't rush—medications in particular require attention and safe administration.
What is 'prioritizing without assessment'?
Making decisions based on assumptions, incomplete assessment, relying solely on someone else's assessment, or failing to reassess.
Why is 'always doing the easiest task first' a problem?
The easiest task isn't necessarily the most important or urgent task.
What is a common mistake involving the client?
Failing to include the client in care, including ignoring preferences and individuality.
What is oxygenation?
The process of providing oxygen to all cells of the body.
What are the two major processes involved in how the respiratory system works?
Ventilation and respiration.
What is ventilation?
The combination of inspiration and expiration.
What happens during inspiration?
Air is brought into the lungs.
What happens during expiration?
Carbon dioxide is expelled from the body.
What happens to the diaphragm during inhalation?
It contracts.
What happens to the diaphragm during exhalation?
It relaxes.
What is respiration?
Exchange of oxygen and carbon dioxide at the cellular level.
What structures make up the upper respiratory tract?
Nose, mouth, pharynx, and trachea.
What structures make up the lower respiratory tract?
Lungs, bronchi, bronchioles, and alveoli.
How many lobes does the left lung have?
2 lobes.
How many lobes does the right lung have?
3 lobes.
What is the pleural space?
The space between the two pleural layers containing a small amount of fluid that allows smooth lung movement.
What are alveoli?
Air sacs at the ends of bronchioles and the site of gas exchange.
What gas diffuses from the alveoli into the blood?
Oxygen (O₂).
What gas diffuses from the blood into the alveoli to be exhaled?
Carbon dioxide (CO₂).
What does surfactant do?
Maintains surface tension and prevents alveolar collapse.
Is breathing controlled automatically?
Yes. The autonomic system controls automatic breathing.
What two blood-gas changes stimulate respiratory receptors?
↑ CO₂ or ↓ O₂.
What do changes in O₂ and CO₂ affect?
The rate and depth of ventilation.
What are the four techniques used in a physical respiratory assessment?
Inspect → Palpate → Percuss → Auscultate.
What is auscultation?
Listening to body sounds with a stethoscope.
What are early cues of inadequate oxygenation?
Shortness of breath, difficulty speaking, restlessness, irritability, confusion, bluish discoloration, and self-positioning/leaning forward.
Why is increasing restlessness or confusion important?
It can indicate inadequate oxygenation.
What position might a patient with breathing difficulty naturally assume?
Leaning forward or against a table.
Where are bronchial breath sounds normally heard?
Over the trachea.
What do bronchial sounds sound like?
Loud and high-pitched.
Where are bronchovesicular sounds heard?
On the sides of the sternum and between the scapulae.
Where are vesicular sounds heard?
Over the peripheral lung fields, especially the bases.
What do vesicular sounds sound like?
Soft and low-pitched.
What is stridor?
A high-pitched sound associated with narrowing/blockage of the trachea or larynx, usually heard on inspiration.
What are crackles?
High-pitched popping sounds, usually on inspiration, associated with fluid in the lung fields or localized atelectasis.
Do crackles usually clear with coughing?
No.
What are rhonchi?
Coarse, low-pitched sounds caused by mucus/secretions in the bronchi.
Can rhonchi clear with coughing?
Yes, possibly.
What is wheezing?
A high-pitched whistling sound caused by narrowed bronchi, commonly from swelling/inflammation.
What is a pleural friction rub?
A low-pitched grating/creaking sound caused by inflamed pleural surfaces rubbing together.
What is hypoxemia?
Decreased oxygen in the blood.