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prairie u6
notes
| Question | Answer |
|---|---|
| Assessing | systematically collect |
| Diagnosing | Analyzing that data & identifying client problems |
| Planning | Develop holistic plan of individualized care (planning nursing goals) |
| Implementing | executing the plan (putting it together) |
| Evaluating | evaluate the effectiveness of the plan of care |
| Inductive reasoning | Use specific data to identify a type of general data, |
| Inductive reasoning | Practical: leaves, Bark, branches = tree |
| Inductive reasoning | Nurse: Elevated vitals and adventitious lung sounds = Pneumonia |
| Deductive reasoning | General data to know what specific data to expect |
| Deductive reasoning | Practical: Tree= Leaves, Bark, Branches |
| Deductive reasoning | Nurse: Pneumonia= elevated vitals and adventitious lung sounds |
| Step 1 Assessment | You see it. A huge nail is sticking out of one of the rear tires and the tire is noticeably deflated. |
| Step 2 Diagnosing | You determine that you have a flat tire. |
| Step 3 Planning | You can replace the tire by changing out the flat one with the spare in the trunk. Good thing you took that class in how to do simple maintenance and repairs on a car! (developed a goal and intervention) |
| Step 4 Implementing | You get the jack and spare tire out of the trunk, roll up your sleeves and get to work. |
| Step 5 Evaluating | After the new tire is installed , You begin slowly to test the feel as you drive. Good. Everything seems fine. The spare tire seems to be OK . (Determined if your goal was met). |
| Objective data | You can see it and measure it with your senses Example: Vitals |
| Subjective data | stated or said it is based on opinion What people say about themselves How much pain they have in their wrist |
| Variable data | Data changes Example your blood presure |
| Constant data | Data doesn’t change Example: Blood Type |
| Primary Sources of data | From the client |
| Secondary Sources of data | Data from someone else EX:Lab work, Chart, Family |
| Tertiary Sources of data | Our research which is Essential in making decisions |
| observational data | Using all your senses, Must be developed senses and observational skills |
| Data by Interviewing | get info by asking questions |
| Data by Examining | Physical assessment |
| Awake (LOC) | Responding |
| Alert (Basic need) | Initiates conversation and responds appropriately |
| Lethargic (loc) | Sleeps most of the time when not stimulated |
| Responsive to verbal stimuli (loc) | responds when name is call ed |
| Responsive to painful stimuli (loc) | responds only to painful stimuli |
| Incoherent (loc) | Speaks in disjointed fashion, thoughts are unrelated dangling sentences |
| Confusion (loc) | Temporary interference with clear thinking process |
| Semi conscience (loc) | responds to painful stimuli |
| Comatose (loc) | No reaction to stimuli |
| Stuporous (loc) | conscience most o the time; can arouse by shacking and shouting; inappropriate verbal |
| Will lose orientation | (in usual order) Time, Place, Person |
| Physical Assessment - Inspection | look and observe Head to toe Ex: look at skin breakdown when giving a bath |
| Physical Assessment - Palpation | Touch used when feeling a pulse (Soft or hard, Can feel vibration Ex. Brachial pulse) |
| Physical Assessment - Percussion | tapping senses of hearing and touch are used ( Used to find the presence of fluid ) |
| Physical Assessment - Auscultation | Using a stethoscope ( Lung and bowl sounds, Listening to a pulse ) |
| Collect Data | Observing, interviewing, examining |
| Validate & Verify data | Data must be accurate. Test accuracy with staff or family |
| Organize data | Organize by basic needs |
| Identify patterns | Identify patterns of problems or groups of problems |
| Report & record data | write down and record pertain ant information |
| Collect Data | Observing, interviewing, examining |
| Validate & Verify data | Data must be accurate. Test accuracy with staff or family |
| Organize data | Organize by basic needs |
| Identify patterns | Identify patterns of problems or groups of problems |
| Report & record data | write down and record pertain ant information |
| Nursing Diagnosis (Analysis) | “ The Unhealthy Response” (2nd step) Actual or potential health problem that can be prevented or resolved by independent nursing intervention |
| Actual nursing diagnosis | Judgment validated by presence of major defining characteristics statement about a health problem that the client has and the benefit from nursing care |
| Risk For nursing diagnosis-(“potential for”) | “At risk for potential problem.” Looks at what an individual might be vulnerable to A statement about health problems that a client doesn't have yet, but is at a higher than normal risk of developing in the near future. |
| Wellness nursing diagnosis | What a healthy person can do to enhance their health, Describes an aspect of the client that is at a lower level of wellness to the higher level of wellness. |
| Medical DX | |
| Nursing DX | |
Created by:
rjh
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