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FUNDAMENTALS 2

CHAPTER 18

QuestionAnswer
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-initiatedPhysician-initiated Collaborative Goals can be:Short termLong term Goals can also be categorized as: Psychomotor-LEARNING NEW GOALAffectiveCognitive-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
Created by: Seka_nurse
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