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N212 TLO 3.3

Nursing PRocess

Definition of NP Variation of scientific reasoning that allows nurse to organize nursing practive,
NP provides a common language for nurse to do what think through clients clinical problems
this process allows nurses to modify what care as needs pt change
what is the purpose of NP DX and treat human responses to actual of potential problems
treating human responses is different from physician treatment how nurses treat human responses, while physicians treat disease
what are the five phases of the nursing process assessment, nursing diagnosis, planning, implementation and evaluation
why do nurses use critical thinkinng to make informed desicians of the client
critical thinking: what are the components of it knowledge base, nursing experience, critical thinking competencies, attitude, confidence, fairness, risk taking, curiosity, integrity, perseverance, creativity,
Criticatl thinking standards: what are the intelectual standards; the professional standards logical, clear, accurate; ethics, responsibility
NP- Assessment: def; what is the purpose collection of pt current and past health statuss on which to base care; to establish a database about client's perceived needs, health problems and responses to these problems
NP: Nursing diagnosis -Def; this is the 2nd part of what; in the ND you analyze what is the act of identifying and labeling human responses to actual of potential problems/life processes; assessment; all assessment data;
NP: Planning- def; what are the goals; nurses identify what goals are set; desired outcomes of the patient; appropriate nursing actions
NP: implementation/intervention- def; the activation of the plan with the use of the nursing inteventions (perform the nursing actions identified in planning
NP: Evaluation- def; do we eval goals on interventions determines if the pt goals have been met as a result of nursing inteventions; goals
NP Assessment- what are the 2 steps collection and verification of data and analysis of data to develop ND and and individual plan of care
NP Assessment- what are the 2 types of data; def of subjective; def of objective; Data is measured based on what subjective and objective; clients perception about their health problems; observation or measurements made by the datat collector; accepted standards (cm, Kg, etc)
NP Assessment- what are the sources of data; what are the 3 methods of data collection; pt, fam, sig. other, health care team , records, lit review, experience; interview, physical exam, diagnostic tests
NP Assessment- NP Assessment- what is obtained in the interview; what type of physical exam; health history; head to toe exam and IPPA;
what does IPPA stand for inspection, palpate, percuss, and auscultate
NP Assessment- interview: what are the 3 phases; def of orientation phase; def of working phase; def of termination phase; orientation, working, termination phase; introduction, purpose of interview; nurse gathers info r/t clients health status; summarize important points, validate this with client, indicate when you will be backq
def of clinical manifestations used to describe the objective and subjective data obtained from a pt that are commonly associated with a clinical problem
objective data is aka; subjective data is aka signs; symptoms
7 cue categories used to analyze a symptom: what are they; location, quality, quantity, chronology, setting, aggravating/ alleviating factors, associated manis, meaning of symptom to pt
7 cue categories used to analyze a symptom: location- ask; record where do you feel it, where is it located; region of body, local radiating, superficial and deep
7 cue categories used to analyze a symptom: quality- ask; record what does it feel like; pt analogy
7 cue categories used to analyze a symptom: quanity- ask ; record how often do you have this feeling, hoe bad is it, how much is it; frequenc, volume, size extent, number
7 cue categories used to analyze a symptom: chronology: ask; record when was the first time it occured, any time of day, week month; time of onset, duration, periodicity and frequency
7 cue categories used to analyze a symptom: setting- ask; record where are you when this occurs?, what are you doing; where pt is when it occurs, what pt is doing, if symptom is rt anything
7 cue categories used to analyze a symptom: aggravating/ alleviating factors- ask; record what makes it better/ worse, any activity that seems to cause it?, what have you done for it; influence of physical and emotional activities, pt attempt to alleviate the symptoms
why is the nursing process important it provides an organizing framework for the practice of nursing and the knowledge, judgment and action that that nurses bring to patient care.
NP Assessment- what is the purpose; what are the 2 steps of assessment; to establish a database about client's perceived needs, health problems and responses to these problems; collection of data and analysis of data
NP Assessment- how does this lead to the ND; the analysis of data leads to develop the ND and plan of care based on actual or potential health problems
NP Assessment- health history- def; what is ROS major component of assessment and it is data r/t current level of wellnes, review of body system, family, health and sociocultural hx, spiritual health, and mental health; review of systems - this is info r/t each body system and any changes
NP Nursing diagnosis- when was the first conference held to identify nursing knowledge and establish a class of systems; what is NANDA; what does nanda do; 1973; north american diagnosis association established in 1982; reviews and accepts nursing dx to be addedto the list
for clinical does nrsg dx have to be nanda yes
def NIC; def NOC nursing intervention class; nursing outcome class
NP Nursing Dx: def; what is the purpose clinical judgement r/t individual, family, or community responses to actual or potential health problems/ life process; it provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
NP Nursing Dx: what is the process of it; how is the data clustered interpret and analyze meaning of assessment data; group of s/s, classified and organized,look for defining characteristics, identify client need, formulate nrsg dx
NP Nursing Dx: diff between nrsg dx and care plans in nrsg dx there is an assessment then one problem is solved in the pt in the care plan there is a collection of nursing dx for the pt
nrsg dx vs med dx: nrsg dx- requires what intervention; what is scope of practice; how many nrsg dx; does the dx change of stay the same; what is the focus on; nurses provide what nursing; scope of nursing practice; multiple; changes; human response; care
nrsg dx vs med dx: why are there multiple dx for pt b/c we are dealing with effects of new problem on person
nrsg dx vs med dx: med dx- requires what intervention; what scope of practice; single of multiple dx; does dx change or stay the same; what is the focus on; what do phys provide medical; medical scope of practice; single; stay the same; the disease; the cure
NP Nursing Dx: provides the basis for what; what did NANDA develop; the selection of nursing interventions; a standardized nursing terminology for identifying, defining, and classifying pt actual or potential responses to health probs
NP Nursing Dx: a nursing dx is not what a disease process, a normal need, a normal developmental level, a nursing problem, a tx or therapy
NP Nursing Dx: what are errors nurses make when dx they have insufficient data used with a label, sufficient data but wrong label, invalid data, renaming a medical problem, legally inadvisable or judgmental label
NP Nursing Dx: the statement can be written in how many parts; the number of parts depends on what; 1,2 or 3 statement; the nrsg dx being used;
NP Nursing Dx:one part statements are used for what; when is a 2 part dx acceptable; wellnes ndx; only if the s/s data are easily accessible to other nurses caring for the patient and for risk dx;
NP Nursing Dx: why is risk dx a 2 part statement; when is 3 part statement used; b/c s/s are not present (they are at risk); during the learning process
NP Nursing Dx: 3 part statement identifies what; what is the format for 3 part statement; what is PES critical thinkning process that occurs in making the judgment about the pts health status; PES; problem ,etiology, s/s
NP Nursing Dx: PES- problem def; ex problem; etiology def; ex etiology; s/s def; ex s/s the nrsg dx label, the term taht reflects the pattern of cues; pain; a brief description of the probable cause of the problem, contributing or r/t factors; r/t surgical incision, edema; a list of the cluster of s/s data the lead to problem; aeb isolation
NP Nursing Dx: what is the r/t portion of PES; what is the label portion of PES; what is the as evidenced by portion of PES etiology; the problem; the s/s
NP Nursing Dx: Etiology- this is a brief description of what; the r/t must be something the nurse can what; what should not be the primary etiology; the probable cause of the problem; tx; the medical dx- it can be secondary to it
NP Nursing Dx: s/s- def; ex; this is a list of data that lead nurse to pinpoint the problem; aeb verbalization of pain, isolation, withdrawal secondary to colon resection
NP Nursing Dx: Types- actual: def; supported by what; how many parts; example; describes human responses to current health problems; defining characteristics; 3; impaired skin integrity r/t prolonged immobility secondary to fx pelvis, aeb a 2 cm lesion on back
NP Nursing Dx: Types- risk/high risk: def; how many part statement; example describes human responses to problem that may develop in a vulnerable individual, family or community; 2 parts; risk for injury r/t lack of awareness of hazards
NP Nursing Dx: Types- possible: def; how many part statement; example describe a suspected problem requiring additional data; 2 parts; possible disturbed body image r/t isolatinf behaviors psot surgury
NP Nursing Dx: Types- wellness: def; how many part statement; example reflects transition from a specific level of wellness to a higher level of wellness; one part; readiness for enhanced nutrition
NP Nursing Dx: Types- syndrome: def; how many part statement; what are the 5 ones cluster of predicted actual or high risk nursing dx r/t a certain event of situation; usually 1 part sometimes 2; rape trauma, disuse, post-trauma, relocation stress, impaired environmental interpretation syndrome
NP Nursing Dx: Types- collaborative: def; how many part statement; who prescribes tx; written how actual or potential phys. complications that can result from disease, trauma, tx or diagnostic studies for whicn nurses intervene in collaboration w/ personnel of other health care disciplines; one part; nurse and doc; risk for complication
NP nursing DX: s/s: s/s are aka; def of major s/s; def minor defining characteristics; are those s/s that are usually present when the dx exists; evidence of a possible nursing dx
NP Planning: NOC- def; behavior is measured along what; research basedm standardized language for nursing outcomes to eval effectiveness of nursing interventions; a continuum to eval progress towards achieving the outcome
what is the diff between a goal or outcome a goal is broad, outcome is focused
NP Planning: what needs should be met first; what is pt outcome; physical b4 phsyological; describe to what degree the patients response identified in the nursing dx should be prevented or changed as a result of nrsg care
NP Planning: goals- what are the guidlines; how many behaviors per goal; realistic, mutual, include short and long term goals, include all 5 components, use measurable observable verbs; one (ex no not wirte denies pain and N at end of shift);
NP Planning: def of short term goals; def of long term goals progrss towards LT goals; usually discharge goals
NP Planning: goals- what are the components of goals; subject, verb, condition, criteria, time;
NP Planning: goals- what are ex of measurable verbs identify, list, describe, discuss, perform, demonstrate, give ,administer, state, verbalize, sit, stand, walk, relate, share, exoress, has absense of, exercise, communicate, explain, cough
NP nrsg inverventions: choosing interventions must be r/t what; interventions have to refer to what; nurse must have what to perform interventions altering the etiological factors; research articles or evidence-based practice protocols; skills
NP nrsg inverventions: def; is any tx based on clinical judgement and knowledge that a nurse performs to enhance pt outcomes
NP nrsg inverventions: what is the nursing order for interventions what, when, how often, how long and where
NP evaluation: what is compared; what is done next with problem; the pt response to goals; continue, revise, or discontinue problem
Created by: jmkettel