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Stack #171444

Nursing Process- Potter and Perry 7th Edition

A professional nurse's approach to identify, diagnose, and treat human responses to health and illness. Nursing Process
A systematic, validation, communication collection of data as it is related to the client. Nursing Assessment
The purpose of an assessment is to establish this about the client's perceived needs, health problems, and responses to health problems. Database
Sources of obtaining data for Nursing Assessment: 1)Primary Source 2)Secondary Sources:(Family and significant other),Health Care team,Medical records.
3 Phases of Assessment Interview: 1)Orientation- introduces self, your position, and explains purpose of interview. 2)Working- gather information about client's health status. 3)Termination- gives client a clue that interview is coming to an end.
This prompts clients to describe a situation in more than one or two words. Open Ended Questions
This limits the client's answers to one or two words such as "yes" and "no" or a number or frequency of a symptom. Closed Ended Questions
This is client told data. Subjective Data
This is nurse observed data. Objective Data
The 5 Steps of Nursing Process: 1)Assessment,2)Diagnosis,3)Planning,4)Implementing,5)Evaluation.
Published in 1967. The first nursing diagnosis book.
Clinical judgment about client response to actual or potential problem based on data collected during assessment. This provides basis for selecting nursing interventions to achieve outcomes. May change frequently. Nursing Diagnosis
An actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status. Collaborative Problem
Clusters and patterns of data contain this, a critical criteria or assessment findings that support an actual nursing diagnosis. Contains subjective and objective data. Defining Characteristics
4 Physical Assessment Techniques: 1)Observation- what you see. 2)Auscultation- listening with or without stethoscope.3)Palpation- feeling with fingers.4)Percussion
Objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion. Clinical Criteria
Describes human responses to health conditions/ life processes that will possibly develop in a vulnerable individual, family or community. Risk Nursing Diagnosis
A clinical judgment of a person's, family's, or community's motivation and desire to increase well- being and actualize human health potential as expressed in their readiness to enhance specific health behaviors. Wellness Nursing Diagnosis
The name of the nursing diagnosis as approved by NANDA International. Diagnostic Label
A condition or etiology identified from the client's assessment data. It is associated with the client's actual or potential response. Related Factor
The "why" of nursing diagnosis. Environmental or contributing factors. Etiology
5 Components of Critical Thinking: 1)Specific Knowledge,2)Experience,3)Competencies,4)Attitudes,5)Standards.
3 Basic Levels of Critical Thinking: 1)Basic-based on rules or principles.2)Complex-separate from authorities. 3)Commitment-makes choices without assistance of others.
3 Purposes of Nursing Process: 1)Identify client's health needs,2)establish nursing care plan,3)complete interventions.
3 Steps of Nursing Diagnosis: 1)Data interpretation and analysis,2)Reaching conclusion,3)Formulating the nursing diagnosis.
Interpretation and Analysis of Nursing Diagnosis: 1)Recognize significant data-compare to standards,2)Validate the data-recheck data, troubleshoot equipment, compare subjective and objective data, clarify patient statements with family or other staff.3)Recognize patterns or clusters.
4 Types of Nursing Diagnosis: 1)Actual,2)Risk for,3)Health Promotion,4)Wellness,5)Potential Complication.
Formulate diagnosis statement by using PES format. What does PES stand for? P= problem: describe patient's health state.E= etiology: factors causing or contributing.R/TS= signs/ symptoms: data collected signaling existence of a problem. AMB
Only use these letters of PES when there is a risk for or Potential Complication problem exists. PE
Utilizes the Nursing Diagnoses to determine the nursing action systems needed to formulate an individualized plan of care for the client to meet their needs. Orem's definition of Planning Phase
The Planning Phase is of Nursing Process is composed of: goals/ outcomes,interventions/ nursing orders.
5 reasons why there is a Planning Phase of Nursing Process: 1)to individual care,2)to set priorities (most important of all),3)to facilitate communication among staff,4)to promote continuity of care,5)to evaluate patient response to care.
The ordering of nursing diagnosis or client problems using notions of urgency and/ or importance to establish a preferential order for nursing actions. Priority setting
The 3 Phases of Comprehensive planning-setting priorities: 1)Initial- first patient contact.2)Ongoing- continuous to meet current needs.3)Discharge-extension of care after discharge.
Priorities are ranked as: 1)High risk 2)Medium risk 3)Low risk
This risk if left untreated can cause harm to client or others. High Risk
These risks are non- emergent, non- life threatening but are still important. Medium Risk
This risk is not necessarily related to current condition. But if left alone affects future well being. Low Risk
This is specific and measurable, client centered, highest possible level, only 1 behavior/ response, worded with a sentence (subject- client, verb, criteria, time). Goal
This is the desired results of actions taken to achieve a broader goal, measurable steps toward achieving the desired results, multiple coutcomes in a goal, complete sentence not necessary (verb, criteria, time) Outcome
Knowledge deficit r/t use of crutches AMB " I have never used crutches before." This is an example of? A Nursing Diagnosis
Patient will walk unassisted with crutches by discharge. This is an example of? A Goal
Voices understanding of instructions given after education, demonstrates appropriate technique for crutch walking (unassisted) prior to discharge to home. This is an example of? Outcomes
There are 2 types of Goals:1) This goal has a time frame of 1 week or less.2) This goal has a time frame of several days to months. 1) Short term goal. 2) Long term goal.
This is most important when setting goals. Considering what the client is willing to do or can do.
A specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. Client- centered goal
Interventions are derived from this statement of the nursing diagnosis. Etiology
This should be individualized, client specific, consistent with the standards of care, realistic in terms of abilities, resources, time and capatible with client's values and beliefs. Interventions
3 Types of Interventions of Nursing Process: 1) Independent- initiated by nurse without directions of other healthcare provider.2) Dependent- carrying out physician directed orders.3) Collaborative-actions performed jointly with other healthcare providers such as PT,OT.
This enhances the continuity of nursing care by listing specific nursing interventions needed to achieve the goals of care. Nursing Care Plan
What 4 questions will help you in designing a care plan intervention? 1)What is the intervention?2)When should each intervention be implemented?3)How should the intervention be performed for this specific client?4)Who should be involved in each aspect of intervention?
Nursing Interventions should be these 4 C's: 1)Clear2)Concise3)Complete4)Correct
Well written nursing orders include: 1)Clear and concise described action.2)Use accepted abbreviations only.3)Dated when written.4)Signed by initiating nurse.
5 Comprehensive Orders: 1)Assessments- type, frequency.2)Direct Care Measures-instructs direct care staff of completing intervention.3)Teaching-instructs patient to use or educates.4)Counseling 5)Advocacy-speaks for client.
Types of Care Plans 1)Standardized plan-most frequently used.2)Protocol3)Kardex4)Student care plan5)Case managementCritical pathway
This step of nursing process formally begins after the nurse develops a plan of care. It is the treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/ client outcomes. Nursing Interventions
A document that guides decisions and interventions for specific health care problems or conditions. Clinical guidelines or Protocol
A preprinted document containing orders for the conduct of routine therpies, monitoring guidelines, and/ or diagnostic procedures for specific clients with identified clinical problems. Standing order
This system developed by the University of Iowa helps to differentiate nursing practice from that of other health care professionals. NIC System
The NIC system offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes. NIC Interventions
Activities performed in the course of a normal day. Examples include: ambulation, eating, bathing, dressing, brushing teeth and grooming. ADL (Activities of Daily Living)
Activities that allow the client to be independent in society. Examples include: shopping, preparing meals, writing checks, taking medications. IADL (Instrumental Activities of Daily Living)
This part of the nursing process determines if after application of the nursing process the client's condition or well- being improves. Evaluation
The process of Evaluation involves these 3 things: 1)Identifing criteria- goals and outcomes.2)Collect evaluative data.3)Interpreting and summarize.
After Evaluation, a nurse makes these decisions: 1)Terminate plan of care- no longer needed.2)Modify the plan-goal not met plan to achieve.3)Continue plan of care- goal not met, plan effective, plan still needed.
Evaluation is the formal mechanism to ensure quality of care. Name 5 ways to ensure quality of care: 1)Quality Improvement (CQI,TQM)2)Quality Assurance (QA)3)Outcomes Management4)Nursing Audit5)Self-Evaluation
The transfer of responsibility for the performance of an activity from one individual to another while still retaining accountability for the outcome. Delegation
These can't be delegated. 1)Assessment2)Planning3)Evaluation4)Nursing judgement
5 Rights of Delegation: 1)Right task.2)Under right circumstances.3)To right person.4)With right directions and communication.5)Under the right supervision and evaluation.
2 Types of Communication 1)Verbal2)Written
Created by: just_mary1971
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