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The Nursing Process

Describe Assessment Two parts: 1.) Gather subjective& objective data 2.) Validate& interpret info gathered
Describe Diagnosis Identifying the patients problems
Describe Planning 1.) Set realistic goals of care & desired outcomes 2.) Identify appropriate nursing actions
Describe implementation 1.) Performing the nursing actions identified in planning 2.) Carrying out care plan
Describe evaluation Determine if goals and expected outcomes are achieved
What are some benefits of using the nursing process for the patient Helps patient have a better understanding of what is going on; Gives patient an idea of what is expected out of them; Helps build and promote active involvement; Builds trust relationships
What are some benefits of using the nursing process for health care providers A way to stay organized; contributes to documentation; Helps focus on patient needs; Provides common language for practice; Builds trusting relationships
How does the nursing process provide a framework for accountability and responsibility Forces you to make responsible choices b/c you will be held accountable for your patients plan of action and the care received
What is the purpose of assessing? Gathering all subjective and objective data possible and ensuring its accuracy to be able to use to formulate an efficient plan of care
What is an initial comprehensive assessment? Basic head to toe; quick run-through of entire body
What is a partial/ time lapsed/ ongoing assessment? A reassessment of something pre-existing issue
what is a focused or problem oriented assessment? Focusing on a specific problem; COLDSPA
What does COLDSPA stand for? Character; Onset; Location; Duration; Severity; Pattern; Associated Factors
What is subjective data Information the patient/family/friends gives you
What is objective data Information YOU observe; Facts; NO OPINIONS
What is an inderective approach to interviewing Asking patient open ended questions; allow them to elaborate; build relationship
What is a directive approach to interviewing Asking patient closed ended question; yes or no; helps narrow down possible issues; gets to the point
List advantages for indirective approach Better understand patient issues; allows them to engage; builds relationship between patient and nurse
List disadvantages for indirective approach Patient can get off topic; too much elaboration leads to irrelevant info
List advantages of directive approach You can make quicker diagnosis; helps focus on issue
List disadvantages of directive approach Patient can feel unimportant; causes patient withdrawal; could lose patient interest
What are some important aspects when conducting a patient-centered interview being prepared; being organized; setting the stage; set an agenda; collect assessment/ nursing health history; terminating interview (summarize)
What are common health areas the nurse assesses objective/subjective data; take account of health history
Why is it important to make an assessment in order to form a diagnosis Must have accurate info in order to form a diagnosis...duh
What is a medical diagnosis Identification of a disease or condition based on a specific evaluation of physical signs, symptoms, history, result of diagnostic tests or procedures; Doctor is only one qualified to make this diagnosis
What is a nursing diagnosis Clinical judgement about individual/family/community; response to actual and potential health problems
What is the relationship between critical thinking and making nursing diagnosis It is necessary to be thorough, comprehensive, and accurate when identifying nursing diagnosis that apply to your patient
What are the three parts of writing a nursing diagnosis P.E.S: Problem, Etiology/related factors, Symptoms/defining characteristics
What are characteristics of a proper nursing diagnosis Includes all 3 parts; organized; no blank spaces; proper initials& role/position stated; documenting for yourself only; keep confidential
What are common errors made when collecting data lack of knowledge or skill; inaccurate data; missing data; disorganization
what are common errors made when interpreting data inaccurate interpretation of cues; failure to consider conflicting cues; using insignificant number of cues; using unreliable or invalid cues; failure to consider cultural influences or developmental stage
What are common errors made when clustering data insignificant cluster of cues; premature/ early closure; incorrect clustering
What are common errors made when labeling data wrong diagnostic label selected; evidence that another diagnosis is more likely; condition of a collaborative problem; failure to validate nursing diagnosis with patient; failure to seek guidance
What are essential aspects of the planning stage setting priorities; identifying patient centered goals/ expected outcomes; prescribing individualized nursing interventions; collaborate with patient/family/other healthcare professionals
Why is it important to coordinate a plan of care for the patient and family? To ensure plan is implemented so patient has the best chance possible at moving towards a full recovery
What are some criteria used in priority setting Urgence& importance: (High/life threatening), intermediate (non life threatening), low (effects patient future while being not directly related to illness)
When considering Maslow hierarchy of needs what requires top priority The bottom level; or basic needs of an individual are top priority; as you move up the levels they go down in ranking
What is the purpose of establishing client goals? To achieve the highest level of wellness and independence; realistic and based on patients needs
What is the difference between goals and outcome criteria? Goals are broad statements that describe a desired change and a patients condition/behavior. Expected outcome is measurable criteria to evaluate goal achievement
What are guidelines for writing SMART goals/ outcome criteria Patient centered; singular goal/outcome; observable; measurable; time limited; mutual factors; realistic
What are essential guidelines for writing nursing care plans Generally includes: diagnosis, goals/expected outcomes, specific nursing interventions, and a section for evaluation findings
What is a nurse initiated intervention Independent nursing intervention/actions a nurse initiates
What is a physician initiated intervention Dependent on nursing interventions, actions that require an order from a physician or another healthcare provider
What is a collaborative intervention Interdependent interventions; therapies that require combined knowledge, skill and expertise of healthcare professionals
what are protocols systematically developed set of statements that help nurses, physicians, and other healthcare providers make decisions about appropriate healthcare problems/ conditions
what are standing orders pre printed document containing orders for the conduct of routine therapies monitoring guidelines and/or diagnostic procedures for specific patients with identifying clinical problems
What are essential guidelines for implementing nursing strategies? include reassessing patient, reviewing/revising existing nursing care plan, organizing resources& care delivery, anticipating& preventing complications, implementing nursing interventions
What are the components of the evaluation process Two components: 1.) Examination of a condition or situation 2.) judgement as to whether change has occurred
What is the relationship between critical thinning and evaluation must apply critical thinking to make clinical decisions, and redirect nursing care to best meet patient needs
Discuss the use of standards of nursing care to evaluate responses to interventions Used to determine whether the right interventions have been chosen or whether additional ones are required
Discuss how evaluation can lead to discontinuation, revision, or modification of a health care plan If goals are met you may discontinue care; if goals are not met what so ever, or condition worsens patient needs to be reassessed and a new plan of action must be created; if change takes place and improvement is evident slight revisions may be made
Created by: amandamarie194