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FUNDAMENTALS 2
CHAPTER 18
Question | Answer |
---|---|
NURSING PROCESS | EVIDENCE CRITICAL THINKING TOOL CYCLE-GOAL DIRECTED-CLIENT FOCUS GOT TO REEVALUATE EVERYTHING AT EVERY SINGLE STEP CLINICAL JUDGMENT MODEL |
ASSESSMENT | COLLECTING DATA CONTINUOUSLY THROUGH DIFFERENT STEPS SYSTEMATIC-COMPLETE-RELEVANT-RECORDED PURPOSEFUL -PRIORITIZE-FACTUAL AND ACCURATE ABC-HIERACHY OF NEEDS-ACUTE VS CHRONIC |
TYPE OF NURSING ASSESSMENT | INITIAL(ADMISSION-ESTABLISHED BASELINE) FOCUS(DRIVEN BY SPECIFIC PROBLEM) DERIVED FROM INITIAL EMERGENCY-LIFE-THREATENING-ASSESS AS ONE GO TIME-LAPSED DATA AS TIME GO-SEE PT EVERY 6W) PT-CENTERED-IS PT AT RISK? COMMUNITY AND SPECIAL POPULATION |
ASSESSMENT DATA HEALTH HX PHYSICAL ASSESSMENT HOW PT CARING FOR THEMSELVES-EXPLORE PT COMPLAINTS | SUBJECTIVE-QUOTE PT WORDS OBJECTIVE-OBSERVE LOOK AT CUES TO MAKE AN EDUCATED JUDGMENT |
DIAGNOSIS RISK-VULNERABILITY-DON'T HAVE BUT IS AT RISK FAACTOR PROBLEM-FOCUSES-UNDESIRABLE HUMAN RESPONSE HEALTH PROMOTION AND WELLNESS-PT MOTIVSTION AND DESIRE | PROBLEM- PIECE FROM NANDA-CC ETIOLOGY-REASON FOR PROBLEM OR CONTRIBUTOR FACTOR-PHYSIOLOGY -PSYCHOLOGIC-ENVIRONMENTAL DEFINE CHARACTERISTICS-EVIDENCE-WHAT PT IS PRESENTING IDENTIFY RISK FACTOR |
TYPE OF DIAGNOSIS | MEDICAL DIAGNOSIS-BY MEDICAL PROFESSION-IDENTIFY DISEASE AND DESCRIBE PROBLEM AND DIRECT TREATMENT NURSING DX: INDEPENDANT-DEAL WTH PT RESPONSE TO MEDICAL DX-ACTUAL AND FACTUAL |
OUTCOME IDENTIFICATION AND PLANNING | ESTABLISH PRIORITIES-WHERE PATIENT HAS TO BE WHAT WILL NURSES DO TO RESEOLVE IT? |
OUTCOME GOAL-PLANNING PT CANT WALK TO BATHROOM PT HAS TO AMBULATE 10 FEET W/O STOPPING BY MONDAY | Goals are:Nurse-initiatedPhysician-initiated Collaborative Goals can be:Short termLong term Goals can also be categorized as: Psychomotor-LEARNING NEW GOALAffectiveCognitive-THINK DIFFERENTLY |
OUTCOME/GOAL | INITIAL - ONGOING- DISCHARGE PLANNING-START ON FIRST ENCOUNTER WITH PATIENT HIERACHY NEED- PT PREFERENCE-ANTICIPATION OF FUTURE PROBLEMS-CRITICAL/CLINICAL REASONING |
TIPS FOR WRITING OUTCOME | DO--MEASURABLE AND SPECIFIC-INCLUDE PT AND FAMILY SMART-SPECIFIC-MEASURABLE-ATTAINED-REALISTIC AND TIME BOUND DON'T MORE THAN ONE BEHAVIOR |
INTERVENTION | REWRITE GOAL IF OUTCOMISNT MET. STEPS TO REACH TO GOAL DEVVELOP THROUGH EVIDENCE BASED DATA CLINICAL EXPERIENCE MEDICAL PRACTICE ETHICAL/LEGAL GUIDLINE |
TYPES OF INTERVENTION | DIRECT- INDIRECT-INTERDISCIPLINARY CARE-REALISTIC WORKING AND EDUCATING PATIENT PROTOCOL AND STANDING ORDERS AND I.E TYLENOL IF TEMP IS OVER 100.1 |
EVALUATION NURSE SIGN | WAS THE OUTCOME ACHIEVED? WHAT WORKED OR DIDN'T WORK IF OUTCOME WASN'T ACHIEVE, START ALL OVER, MODIFY CARE PLAN TERMINATE, MODIFY OR CONTINUE(LONG TERM GOAL) 2 PART STATEMENTS, HOW GOAL WAS MET+DATA SUPPORTING PT: MET, PARTIALLY MET, NOT MET |