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what are the 5 components of the nursing process? assessment, diagnosis, planning, implementation, assessment.
what is the definition of the nursing process? An organized sequence of problem solving steps used to ID and manage the health problems of clients.
Who accepts the nursing process for clinical practices? American Nurses Association
Goals of hte nursing process? ID actual and potential health care problems. determine desired outcomes deliver specific nursing interventions to solve the problems. evaluate the care given.
Characgteristics of the NP Goal-directed ... prioritized ... dynamic
Assessment? Carefull observation and eval of clients health status at first sight. Collects data Organize data
Types of data? Measureable Observable
Quick head-to-toe assessment? Initial observation: breathing, how is patient feeling, appearance, affect skin color. Head: LOC, able to communicate, mental status, eyes. Vital signs: temp., pulse, respirations, blood pressure.
Auscultation of lungs. right lung: 3 lobes Left lung: 2 lobes listen to front and back.
auscultation of heart lub-dub sound
Abdomen shape, soft or hard, appetite, last BM, voiding status
auscletataion of bowel sounds ALWAYS look first for bag. do all 4 quadrants then feel for soft or hard, descended, or bag.
Extremeties Pain Tubes and equipment normal movement, skin tugor, and temp., peripheral pulses, edema, cap refill Oxygen, NG tube, catheter, dressings
2nd step DIAGNOSIS analyze data to ID actual or pot health probs. IDs nursing diagnosing Must use NANDA approved diagnosis
What are the 3 parts of nursing diagnosis? Name of problem Cause of problem Sign and symptoms
What are etiological factors? Characgteristcs that must be present for a nursing diagnosis to be appropriate for patient
What are the types of nursing diagnosis? actual, risk, possible, syndrome, wellness
What are the Prioritization of Problems? High priority: life threatening Medium priority: threaten health or coping ability Low priority: No major effect on person on the spot.
What are the problems ranked in order of import? Survival: airway and circulation After that, safety needs
How frequently must work plan be evaluated and reprioritized? Every 2 hours
What is planning? The process of prioritizing nursing diagnosis and collaborative problems, IDing measurable goals and outcomes, selecting interventions, documenting care of plan. Entails consultation with client.
What are 2 types of goals? short term (7-10 days) long term (weeks or months)
What are expected outcomes? A specific statement of the goal the patient is expected to achieve as a result of interventions. Should contain measurable criteria to be evaluated to see if outcomes have been achieved.
SMART Specific, Measurable, Attainable, Realistic, Timed
How does a nurse select strategies? Based on the knowledge that certain nursing actions produce desired effects.
What 3 things should interventions be? Safe, within legal scope of nursing practice, and compatible with nursing orders.
What is a rationale? A concept of reason
What do nursing interventions require? A scientific rationale
What must interventions include? A page number
How can plans of care be documented? Handwritten, computer generated, or standardized or based on agencies clinical pathways
What is the evaluation? Final step. Involves the analysis of the clients response to determin the effectiveness of the interventions.
What is critical thinking? Purposeful outcome directed thinking. Clinsiders client, family and community needs based on principles of nursing process and scientific method, makes judgements based on evidence not conjecture.
Created by: 100000907582862