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Nursing Process

Nursing Process Chapter 11-16 Fundamentals (Freshman)

Nursing processAnswer
Systematic, continious collection, validation, communication of client data Assessing
All pertinent information collected by the nurse and others during the assessment Database
What depends on complete and accurate data during assessment All other pieces of the nursing process
Client responses to health problems are the Data focus
Perceived by the senses, signs overt data, can be verified by another Objective Data
Comes from the client, can not be verified, symptoms Subjective Data
Observation, nursing history (interview, verify by asking), physical assessment are the components of What are the components of data collection?
The assessment must be Complete, Factual, Accurate, Relevant information
Client, Support systems (family), client record, other professionals, literature What are the sources of data in assessment?
Data must always be Validated, Communicated, Documented (if not, it did not happen)
Diagnosing Identifies the causes of the problem
Diagnosing Identifies actual and potential problems
Nursing diagnoses We look at actual or potential health problems that can be prevented or resolved by independent nursing interventions when writing this
5 steps to nursing diagnoses Interpret data, Cluster data, Determine problem areas, and write the _______
To cluster data in diagnoses a nurse needs to make the conclusion No problem, possible problem, actual problem, wellness issue
Actual problem Problem is present (diagnosis)
Risk for problem Patient is vulnerable to developing the problem (diagnoses)
Possible problem More data needs to be established (diagnoses)
Patient already working on the problem and desires to do even better (diagnoses) Wellness issue
Need, due to, neglence, healthy, mediacal diagnosis, permanent, poor, inadequate, abnormal, unhealthy are all Unacceptable terms for diagnoses
Problem-->related to-->etiology (cause)-->as evidenced by (characteristics) Format of a written nursing diagnoses
Nursing diagnosis, how is the problem written? NANDA terms
What are the defining characteristics of the nursing diagnoses? As evidenced by or as manifested by: (subjective and objective data that signal the existence of the problem... the CUES that reflect the existence of the problem.
How is the nursing diagnosis prioritized? Maslow's hierarchy, Client problems, Anticipation of future problems
Identify goals (outcomes) with the client Planning
When we identify interventions to help we are in the ____ process Planning
Complete care plan is a Formal Plan
Moment by moment planning is Informal plan
Initial (on admission), ongoing (reformed from new data), Discharge (begins on admission) are the phases of Planning
Discharge planning is a phase of planning that should include Teaching, counceling to prepare for home/self care
How many goals/outcomes per nursing diagnosis should there be? At least 1 (The patient will ...)
Writing the goals/outcomes can be written in Short term or Long term
What should the goals/outcomes of planning include? Cognitive, Psychomotor, Affective (feelings beliefs and attitudes.. hard to measure)
Cognitive is (goal/outcome) Thought (ability to explain)
Psychomotor is (goal/outcome) Ability to demonstrate
Does the nursing goals/outcomes in planning have to be measurable? Yes
This has a Subject(client), Verb (Action), Condition (how it will be achieved.. not always included), performance criteria (observable, measurable terms), target time (when patient is expected to achieve the ______) Parts of the goal or outcome in planning... how to write the measurable outcomes ex. During the next 24-hour period the patient's fluid intake will total at least 2,000 mL. OR AT the next visit, 12/23/09, the patient will correctly demonstrate exercise
When I say: "The client will... What do I mean? I am establishing the goals/outcome in planning
If a goal is well written, then we will know that we have formed a base to be able to Evaluate whether the patient's problem has been solved
Contains goals/outcomes, Contains nursing orders that establishes specific nursing care to be done for the client to assist in resolving the problem Planning
When I carry out the nursing orders I am Implementing
Another term for implementing Interventions
When I assist the client to achieve health goals or outcomes I am Implementing the nursing orders
What are the 5 types of orders to be implemented? Independent, Dependent, Collaborative, Protocols, Standing
If the nurse follows nursing orders Independent interventions
When the nurse carries out orders by the physician Dependent Interventions
If the physician has the nurse consult the social worker then the nurse carries out the orders Collaborative intervention
Nurse initaited interventions that are written plans that detail the nursing activities to be executed in specific situations Protocols (admission and discharge)
A protocol that empowers a nurse, it initaites certain actions that usually requires an order or supervision of the doctor (emergency situations like bowel interventions, narcotic OD, reverse respiratiory depression) Standing orders (interventions)
A measure of how well a client has achieved goals/outcomes Evaluation
Identifies factors contributing to client's success or failure Evaluating
On evaluation what do we do if we find that the goal is unmet or partially met? Modify, collect more data, delete diagnoses, make goal more realistic, adjust time, change interventions
On evaluation, what are the options? Goal met, Goal partially met, Goal not met
Prepared care plans that ID Diagnosis, outcomes, Interventions common to a specific population Standarized care plans
On admission a nursing history and physical assessment are obtained Initial planning
When a nurse perfects, changes, or updates a care plan prn Ongoing planning
Begins at admission and involves home care, community resources etc. discharge planning
Intial planning, Ongoing planning, and discharge planning are Comprehensive care planning, needs to be kept up to date
Within 1 day of teaching, the patient will list 3 benefits of continuing to apply moist compresses to leg ulcer after discharge (what is this) Outcome cognitive (knowlege increased)
By 6/12/09, the patient will correctly demonstrate application of wet to dry dressing on leg ulcer Outcomes/goals of planning, psychomotor (achievement of new skills)
By 6/12/09, the patient will verbalize valuing health sufficiency to practice new health behaviors to prevent recurrence of leg ulcer Outcome/goals of planning, Affective (changes in value, belief)
Health state, LOS, Growth/development level, values/cultural, other therapies, human/financial resources, Risks/benefits, scientific evidence, changes is stats=need for modification How we determine patient centered outcomes
Thought that is disiplined comprehensive, based on intellectual standards and as a result well reasoned; a systematic way to form and shape ones thinking that funcitons purposefull and exactingly Critical thinking
Promotes critical thinking and self directed learning "critical thinking approach to care plan" Concept mapping
We get baseline data that enables the nurse to make a judgement about the patiens health status, ability to manage (h)is own health care and need for nursing to plan individualized care Initial assessment
Assessment conducted to assess a specific problem; focuses on pertinent history and body regions focused assessment
rapid focused assessment conducted to determine potentially fatal situations emergency assessment
An assessmsent that is scheduled to compare a patiens current status to baseline data obtained earlier Time lapsed assessment
Act of confirming or verifying Validation (objective data)
Condition of health relating to health requiring intervention if disease or illness is to be prevented or resolved and coping and wellness are to be promoted Health problem
An aim or an end. In outcome and planning Goal
Ongoing evaluation program designed and implemented to secure the excellence of healthcare; may involve an assessment of structure, process and outcome standards Quality assurance program
Finding deficient workers and removing them Quality inspection (of quality assurance program)
finding opportunities of improvement (team building) quality as opportunity (of quality assurance program)
Case management plan that is detailed, standardized plan of care developed for a patient population with a disignated diagnosis, or procedure; it includes expected outcomes, list of interventions to be performed and the sequence and timing of intervention Critical/Collaborative Pathway
Method of evaluating the oucomes of nursing care or the process by which of these outcomes are achieved using a review of patient records. Nursing Audit!!
An approved list of running diagnosis NANDA
Maslows heirarcy of needs is used to prioritize the diagnoses (physiological high priority then goes down from there)
What part of ADPIE requires the most documentation due to legalities (if you dont document, it didnt happen) Implementation
Created by: Cinderelle