NUR 205 Exam 1 Study Guide Graded Latest Version

Nursing Process - purpose is to identify and solve a patients problem (Base of nursing) Nursing Process - Phase 1: Assessment-gathering information Phase 2: Nursing diagnosis- analysis and identification of an actual or potential problem Phase 3: Planning- goals and outcomes Phase 4: Implementing- following through with decided plan of action Phase 5: Evaluation- to see if goals/outcomes have been met Care Plan - Is the end product of the nursing process, individualized for the patient Actual Nursing Diagnosis - Actual- actively having the problem (1. Diagnostic label, 2. Related to, 3. As evidence by) Potential Nursing Diagnosis - Potential- risk for has not happened but could pose a problem for the patient later ( Diagnostic statement...risk for nursing diagnosis, related to cause of problem) Etiology - the cause, set of causes, or manner of causation of a disease or condition How to write a nursing diagnosis (statement) - P= problem E= etiology (cause) S= symptoms (evidence) If the etiology is incorrect then the nursing interventions will be ineffective. Etiology can change even if the nursing diagnosis is the same, for example: ineffective breathing pattern can be related to fatigue and anxiety Why do we develop a nursing diagnosis? - The nursing diagnosis drives interventions and patient outcomes, enabling the nurse to develop the patient care plan Who is responsible for the nursing diagnosis? - The RN Who initiates the patient plan of care? - The RN Assessment (Including 60 second assessment) - Obtain patient health history Prioritization General assessment Neurological Cardiovascular Pulmonary Integumentary Gastrointestinal Genitourinary Pain Never Events - Are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicates a real problem in the safety and credibility of a health care facility. The purpose of National Patient Safety Goals - Is to improve patient safety, the goals focus on problems in health care safety and how to solve them Hospital Acquired Conditions (HACs) - Is an undesirable situation or condition the affects a patient and that arose during a stay in a hospital or medical facility. Nurse Sensitive Indicators (NSIs) - Are measures and indicators that reflect the structure, processes and outcomes of nursing care. Clinical Judgement - The ability to make logical, rational decisions and decide whether a given action is right or wrong. Infection Prevention - The most effective measures are using sterile technique, hand hygiene, patient education, use of PPE. Patient Centered Outcomes - Outcomes from medical care that are important to the patient Patient Safety-Considerations in a healthcare setting - Fall Preventions Skin Integrity Quality health care Regulatory Agencies National Council of State Boards of Nursing's positon of social media - Just don't do it, you never know what can or will be said about something you may post. You can lose your license or be fined for your actions. Nurse Practice act - Teaching within the scope of practice, to protect the public. National Council of State Board of Nursing (NCSBN) - Is where you can find the definition of nursing for each state, develops test plans for the RN and LPN NCLEX examination, guides each state in revisions of the nurse practice act Standards of Practice (ANA) - Reflects the thinking of the nursing profession on various issues and should be reviewed on conjunction with state board of nursing policies and practices