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Terms Definitions
List the 4 step nursing process
- based on the _____
- data collection
- planning
- intervention
- evaluation

- scientific method
The 4 step nursing process based on the scientific method identifies ___ then ____ - the problem first
- gathers data
The most important outcome for nurses is ____ - think before acting (do no harm)
List the 5 step nursing process for the RN - assessment (data collection)
- nursing diagnosis
- planning
- intervention
- evaluation
The 5 step nursing process:
- replaced the problem solving method with ____
- provided an organized, unique way of contributing to ____
- reasoning model
- patient care
Systematic gathering and review of info about the patient, which is communicated to appropriate members of the health care team Data Collection
Involves assisting the RN in the development of nursing diagnosis, goals, and interventions for a patients plan of care and maintaining patient safety Planning
Is the provision of required nursing care to accomplish established patient goals Implementation
Compares the actual outcomes to the expected outcomes, which are then communicated to members of the health care team Evaluation
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 Nursing Process
NCSBN integrated the ____ into all areas of the NCLEX-PN examination - nursing process
Nursing Process:
- 2 functions
- 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
Is a summary, in nursing terms, of actual or potential problems that nurses can respond to Nursing Diagnosis
Nursing Diagnosis:
- function
- mandated/developed by
- used by
- function: the problem the patient presented with
- mandated: NANDA
- used by: only RN's
Role differences between RN's and LPN's 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
The LPN uses the nursing diagnosis as the reference point to ___ - identify and resolve patient problems
Patient care is a ____ - learning experience
Assessment Phase
- what is it?
- what is data?
- 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)
Phase 1: Assessment
- when does it begin?
- the ___ is the primary source of information
- 2 types of data
- 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
Subjective Data
- based on
- give example
- sometimes called ___
Objective Data
- based on
- give examples
- sometimes called ____
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
Phase 1: Assessment
- must always ____ the information
- communicate info to appropriate health care team members
- ____ data must be reported immediately
- verify
- emergency
List 3 ways good communication strategies will facilitate patient data collection - 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
Phase 2: Planning
- planning includes assisting the RN to develop ____,____, ____
- nursing diagnosis
- outcomes
- interventions
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
- RN
- True
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 ____
- data and patient needs or problems
- patient functions
- nursing diagnosis - plan of care
Phase 2: Planning
- 3 types of care plans
- 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
Phase 3: Implimentation
- definition
- 4 examples
- 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
Phase 4: Evaluation
- definition
- what it compares
- example
- 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
Maslow's Hierarchy of Needs
- the problem taking priority is one that is potentially ____
-example
- levels of need
- example of lower level needs
- life threatening (ie bleeding, SOB)
- levels: lower levels take priority over higher levels of needs
- lower level: survival related or psychological
Goals / Outcomes
- short term / long term
- length of time for goals
- goals / outcomes definitions
- 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
Outcomes (NOCS)
- must be ___, ___, ___ , and ___
- patient centered
- realistic
- measurable
- time referenced
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
Phase 1: Assessment
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
communication barriers
Phase 2: Planning
~ characteristics of care plans formulated by the RN
- must establish ___
- take care of ___ problems immediately
- must be flexible to accomodate ___
- priorities
- potential life threatening
- a patient's changing needs and condition
Phase 2: Planning
- building on ____ provides a sense of contribution and some control for the patient
- goals and outcomes must have ___, ___, and ___
- patient strengths

- realistic, measurable, time referenced
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 ___
- specifics -desired outcomes
- who, what, where, when, how much
- related to (R/T)
- alternate sources - top of head
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
- Goal
- Outcome
The LPN curriculum equips the graduate to ___ and implement an variety of nursing ___, making a high degree of independence possible in these areas - data collection
- interventions
LPN Nursing Curriculum:
- Nursing Process Education
- Critical Thinking Education
- 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
The nursing process standard that standardizes, defines, and assists in choosing the appropriate nursing interventions
- known as participation
Nursing Interventions Classification (NIC)
The nursing process standard that standardizes terminology and criteria for measurable or desirable outcomes of nursing interventions
- known as goals
Nursing Outcomes Classification (NOC)
Is the source that helps the RN to determine the nursing diagnosis North American Nursing Diagnosis (NANDA)
Is a source for choosing standardized nursing interventions NIC
Identifies desired outcomes as a result of nursing interventions NOC
NIC and NOC can be used alone or linked with nursing diagnosis, using ___ taxonomy NANDA
The aim of both the nursing process and critical thinking is to promote ____ patient safety
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