Nursing diagnosis
Defined as the nurse's clinical judgement about the patient's response to actual or potential health conditions or needs
What is the nursing diagnosis, as defined by the American Nurses Association (ANA)?
A problem-solving approach to clinical decision making using the best available evidence combined with nursing expertise and the patient's unique circumstances and preferences
What is evidence-based practice?
Right task, right circumstances, right person, right directions and communication, right supervision and evaluation
What are the 5 rights of delegation?
Assessment, Diagnosis, Planning, Implementation, Evaluation (ADPIE)
What are the steps of the nursing process?
Caregiver role strain, grieving related to loss of health, unilateral neglect related to disturbed perception from neurological damage
What are nursing care plans for a CVA?
Outcome identification
What is the next step after deciding on nursing diagnosis?
Evidence-based practice means you conduct a research study: true or false?
False. You are taking an active role in using the best available evidence when delivering care.
The distribution of work that each staff member is responsible for during a given work period; performed when the nurse directs other nurses, lPN/VN, and UAP to perform care that is within their scope of practice.
What is assignment?
Reevaluate data, diagnosis, etiologies, outcomes, interventions
What do you do if evaluation of nursing process results in outcomes not met?
Activity intolerance due to weakness, fatigue; decreased cardiac output related to impaired cardiac function, increased preload, decreased contractility, increased afterload; excess fluid volume related to impaired excretion of sodium and water
What are nursing care plans for heart failure?
Developing the clinical question using PICOT format
What is step 1 in the evidence-based practice process?
Includes guidance and direction, oversight, evaluation, and follow-up by the RN. When you delegate, you are responsible for this.
What is supervision of unlicensed assistive personnel (UAP) or LPN/VNs?
Provides a structure for delivering nursing care and the knowledge, judgments, and actions that nurses use to achieve best patient outcomes.
What is the nursing process framework?
Activity intolerance related to imbalance between oxygen supply and demand; ineffective health maintenance related to deficient knowledge regarding self-care and treatment; risk for decreased cardiac tissue perfusion: risk factors: coronary artery spasm, hypertension, hypotension, hypoxia
What are nursing care plans for myocardial infarction (MI)?
1) nursing phenomena—i.e., the focus of nursing, sometimes referred to as nursing diagnoses; 2) nursing interventions—i.e., the actions or activities nurses perform; and 3) nursing outcomes—i.e., the results of nurses' actions in terms of change in the focus at a specific time.
What are the three primary elements of the ICNP (International Classification for Nursing Practice)?
Developing skills to be able to seek and incorporate into practice scientific evidence that supports best patient outcomes
What is implementing EBP
Occurs when one RN leaves the unit for a meal break
What is RN to RN delegation (when 1 RN has accountability for an outcome and asks another RN to perform a specific intervention related to that outcome)?
By collecting assessment data, identifying nursing diagnoses, and selecting patient outcomes and nursing interventions
How do you practice and learn the nursing process?
Excess fluid volume related to decreased urine output, sodium retention, inappropriate fluid intake; risk for electrolyte imbalance: risk factor: renal disfunction; risk for powerlessness: risk factor: chronic illness
What are nursing care plans for kidney failure?
Certain physiologic complications that nurses must monitor to detect the onset of or changes in patient status
Collaborative problems. This is an anticipated problem based on knowledge of pathophysiology and potential complications of medical treatment. Identified as "potential complication" or "PC:"
Well-designed controlled trials without randomization are better than systematic reviews and meta-analysis of RCT(randomized control trials): true or false?
False. Hierarchy of evidence goes from opinion at the lowest level of evidence reliability up to systematic reviews and meta-analysis of RCTs, in which multiple studies are pulled together to create an overarching consensus of evidence.
Because you are accountable for ensuring that delegated tasks are completed in a competent manner
Why must the RN evaluate the care given, follow up as needed, and make sure no care was missed?
Death anxiety related to unresolved issues regarding dying; decisional conflict related to selection of treatment choices, continuation or discontinuation of treatment, "do not resuscitate" decision; constipation related to side effects of medication, altered nutrition, decreased activity
What are nursing care plans for cancer?