| Terms |
Definitions |
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Outcomes (NOCS)
- must be ___, ___, ___ , and ___
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- patient centered
- realistic
- measurable
- time referenced
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Phase 3: Implimentation
- definition
- 4 examples
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- carrying out the nursing orders on the care plan to obtain a goal
- ex: initiate teaching within the LPN role
- support the teaching of the RN
- teaching a mother how to give new infant a bath
- show diabetic how to measure blood sugar by finger pricking
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Is a source for choosing standardized nursing interventions
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NIC
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Phase 2: Planning
- assist in determining a significant relationship between ____ and ____
- focus is on _____ that will benefit from nursing interventions
- once the data is collected and organized, the RN then makes the ____ and formulates the ____
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- data and patient needs or problems
- patient functions
- nursing diagnosis - plan of care
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Phase 2: Planning
- planning includes assisting the RN to develop ____,____, ____
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- nursing diagnosis
- outcomes
- interventions
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Role differences between RN's and LPN's
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RN's: - nursing diagnosis
- independent role in all 5 steps of nursing process
- established list of current nursing diagnosis
LPN: - no nursing diagnosis
- dependent role in planning and evaluation phases
- independent role in data collection and implementation phases
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The 4 step nursing process based on the scientific method identifies ___ then ____
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- the problem first
- gathers data
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List 3 ways good communication strategies will facilitate patient data collection
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- ensure the patient knows who you are and what you are going to do
- clarify what you do not understand w/ the patient
- respectful distancing
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List the 4 step nursing process
- based on the _____
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- data collection
- planning
- intervention
- evaluation
- scientific method
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Phase 4: Evaluation
- definition
- what it compares
- example
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- the process of determining outcome attainment by comparing actual vs desired patient outcomes
- compares: patient's responses w/ the outcome criteria
-ex: (nursing goal) patient will ambulate 2x a day in next 24 hrs; (evaluation) patient ambulated 3x a day within 24 hrs
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Involves assisting the RN in the development of nursing diagnosis, goals, and interventions for a patients plan of care and maintaining patient safety
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Planning
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Subjective Data
- based on
- give example
- sometimes called ___
Objective Data
- based on
- give examples
- sometimes called ____
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Subjective:
- based on: patient's opinions
- ex: patient complaints
- symptoms
Objective:
- based on: data nurse can verify
- ex: v/s, BP, Pulse, Temp, wound w/ saturated dressing
- signs
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Maslow's Hierarchy of Needs
- the problem taking priority is one that is potentially ____
-example
- levels of need
- example of lower level needs
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- life threatening (ie bleeding, SOB)
- levels: lower levels take priority over higher levels of needs
- lower level: survival related or psychological
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The nursing process standard that standardizes, defines, and assists in choosing the appropriate nursing interventions
- known as participation
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Nursing Interventions Classification (NIC)
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Identifies desired outcomes as a result of nursing interventions
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NOC
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Is the provision of required nursing care to accomplish established patient goals
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Implementation
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Is a way nurses communicate with to identify what the nurse will do to safely assist the patient reach desired patient goals; provides for continuity of safe care for patients
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Nursing Process
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Nursing Diagnosis:
- function
- mandated/developed by
- used by
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- function: the problem the patient presented with
- mandated: NANDA
- used by: only RN's
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Phase ___ Examples:
- observing results of a laxative or enema
- observing behavior for signs of diorientation or confusion
- observing family interaction
- observing the env. for for need for safety factors
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Phase 1: Assessment
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Phase 2: Planning
~ characteristics of care plans formulated by the RN
- must establish ___
- take care of ___ problems immediately
- must be flexible to accomodate ___
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- priorities
- potential life threatening
- a patient's changing needs and condition
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LPN Nursing Curriculum:
- Nursing Process Education
- Critical Thinking Education
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- Nursing Process Edu: enables the nurse to care for patients in a systematic manner
- Critical Thinking Edu: allows the nurse to analyze a situation and choose the best intervention for the patient
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Phase 2: Planning
- only the ___ can develop the plan of care, nursing diagnosis, goals, and interventions
- (T/F) it is illegal for the LPN to write the plan of care and have the RN initial or sign off on it
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- RN
- True
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NCSBN integrated the ____ into all areas of the NCLEX-PN examination
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- nursing process
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Phase 2: Planning
- 3 types of care plans
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- Standardized: based on research of the best possible options for a nursing diagnosis
- Computerized: individualized plans that can be entered into the computer
- Multidisciplinary (collaborative): developed by multidisciplinary team, reflect specific interventions used by each discipline
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Systematic gathering and review of info about the patient, which is communicated to appropriate members of the health care team
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Data Collection
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Phase 2: Planning
- building on ____ provides a sense of contribution and some control for the patient
- goals and outcomes must have ___, ___, and ___
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- patient strengths
- realistic, measurable, time referenced
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Compares the actual outcomes to the expected outcomes, which are then communicated to members of the health care team
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Evaluation
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NIC and NOC can be used alone or linked with nursing diagnosis, using ___ taxonomy
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NANDA
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Phase 1: Assessment
- must always ____ the information
- communicate info to appropriate health care team members
- ____ data must be reported immediately
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- verify
- emergency
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The LPN curriculum equips the graduate to ___ and implement an variety of nursing ___, making a high degree of independence possible in these areas
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- data collection
- interventions
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The following characteristics are examples of possible _____ in data collection
- inadequate assessment of skills
- presence of distractions
- insufficient time
- inability to speak the language
- patient labeling
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communication barriers
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Phase 2: Planning
~ Nursing Interventions
- identify ___ to do that assist the patient to reach ___
- specifies ____ to nursing personnel
- focus on the ___ portion of the nursing diagnosis
- based on info from ___, and not from ___
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- specifics -desired outcomes
- who, what, where, when, how much
- related to (R/T)
- alternate sources - top of head
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The aim of both the nursing process and critical thinking is to promote ____
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patient safety
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Is a summary, in nursing terms, of actual or potential problems that nurses can respond to
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Nursing Diagnosis
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The nursing process standard that standardizes terminology and criteria for measurable or desirable outcomes of nursing interventions
- known as goals
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Nursing Outcomes Classification (NOC)
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Patient care is a ____
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- learning experience
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Nursing Process:
- 2 functions
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- provides structure for reasoning, a way for nurses to identify and respond to patient needs within the scope of nursing
- an orderly way of developing a plan of care for individual patients
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Goals / Outcomes
- short term / long term
- length of time for goals
- goals / outcomes definitions
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- short term: 4-8 hours or 2-4 days
- long term: 1-2 weeks
- goal: state a general intent
- outcome: describe a result that can be observed at a specific point in time
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The following are examples of ___ and ___:
- "I will learn the medical prefixes, roots, and suffixes by the end of the semester"
- "I will learn the medical prefixes, roots, and suffixes well enough by the end of the semester to get an A on
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- Goal
- Outcome
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Phase 1: Assessment
- when does it begin?
- the ___ is the primary source of information
- 2 types of data
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- begins: upon admission and continues with each patient encounter
- patient
1.) subjective- based on patient's opinion or report
2.) objective- data nurse can verify or measure
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List the 5 step nursing process for the RN
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- assessment (data collection)
- nursing diagnosis
- planning
- intervention
- evaluation
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Assessment Phase
- what is it?
- what is data?
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- when the LPN collects data about the patient
- data: is everything that relates to the patient (v/s, allergies, head to toe assessment, chief complaints, patients history)
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The LPN uses the nursing diagnosis as the reference point to ___
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- identify and resolve patient problems
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The 5 step nursing process:
- replaced the problem solving method with ____
- provided an organized, unique way of contributing to ____
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- reasoning model
- patient care
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The most important outcome for nurses is ____
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- think before acting (do no harm)
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Is the source that helps the RN to determine the nursing diagnosis
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North American Nursing Diagnosis (NANDA)
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