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VNSG 1400 Exam 1

Nursing in Health and Illness

A way of thinking and acting based on the scientific method the nursing process
coverting info and establishing a care plan for each patient process
Five components of the nursing process Assessment, nursing diagnosis, planning, implementation, and evaluation
Assessment (data collection) careful observation and evaluation of a patient's health status
Nursing diagnosis identify actual or potential health problems
Prioritize problems, identify goals and document plan planning
carry out nursing orders implementation
evaluate care given evaluation
Characteristics of nursing process goals, prioritized, and dynamic
directed the nurse and the patient work together to achieve set goals Goals
focused care resolves the health problems with the greatest risk first Prioritize
always changing as the patient changes Dynamic
Organize your data by body systems
Signs Vital signs, anything that can be measured
Symptoms information that only the patient feels and can describe
Objective Data Signs
Subjective Data Symptoms
Breathing, how is the patient feeling, appearance, affect(mood), skin color Initial observation
Level of consciousness, able to communicate, mental status, and appearance of eyes Head
Temp, pulse, respirations, and blood pressure Vital Signs
Listen to front and back Auscultation lungs
Listen to lub-dub sounds S1 and S2 Auscultation of heart
shape, soft or hard, appetite, last BM, voiding status Abdomen
Always look first, listen to all four quadrants, then feel auscultation of bowel sounds
To legally chart no bowel sounds you must listen to each quadrant for how many minutes five
Normal movement, skin turgor, temp, peripheral pulses, edema, cap refill Extremities
The nursing diagnosis includes three parts the name and cause of the problem, and the s/s
Collaborative problems are potential complications
Nursing diagnosis defines the patients response to illness
Medical diagnosis labels the illness
NANDA identifies five types of nursing diagnosis Actual, Risk, possible, syndrome, and wellness
Health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures Nursing Diagnosis
a problem that currently exist Actual
a problem the patient is uniquely at risk of developing Risk
a problem may be present, but requires more data collection to rule out or confirm its existence Possible
What two types of nursing diagnosis must include the problem, cause and s/s Actual and Risk
cluster of problems predicted to be present because of an event of situation Syndrome
a health related problem that the patient initiates with which a healthy person obtains nursing assistance to maintain or perform at a higher level Wellness
placing nursing diagnosis/interventions in order of importance Priority setting
life threatening problems high priority
problems that threaten health or coping ability Medium priority
problems that do not have a major effect on the person if not attended to that day or week Low priority
the process of prioritizing nursing diagnosis and collaborative problems, identifying measurable goals and outcomes Planning
while developing and revising the plan the nurse must consult with the patient
a broad idea of what is to be achieved through nursing interventions Goal
are those that are achievable within 7-10 days or before discharge Short term goals
goals that take weeks or months to achieve long term goals
are derived from the goals expected outcomes
should also contain measurable criteria that can be evaluated to see whether the outcome has been achieved expected outcomes
an expected outcome should be realistic and attainable and should have a defined time line
Specific, Measurable, Attainable, realistic, and timed SMART
state goals in a way that spells out the end result you want to achieve Specific
how will you know when you have met your goal Measurable
can the goal be met as stated Attainable
can you reasonably expect to achieve your goal Realistic
set a time frame for accomplishment and re-evaluation of your goal Timed
planning the measures that the client and nurse will use to accomplish identified goals involves critical thinking
are directed at eliminating etiologies Nursing interventions
must be safe, within legal scope of practice, and compatible with medical orders Nursing interventions
a concept of reason Rational
all nursing interventions require a scientific rational
can be hand written, standardized, computer generated, or based on an agency's written standards or clinical pathways Plan of care
the plan of care should be reviewed and updated once every 24 hours
the nurse shares the plan of care with nursing team members, the client, and clients family
carrying out the written plan of care, performing the interventions, monitoring the patient's status and assessing and reassessing the client Implementation
independent nursing diagnosis needs no physicians order
dependent nursing diagnosis needs a physicians order
deciding whether the interventions have helped the patient Evaluation
it is the analysis of the client's response, evaluation helps determine the effectiveness of nursing care Evaluation
if goals are not reached the plan must be revised
will make nurses more efficient and effective at resolving situations developing good critical thinking skills
a key feature is the ability to maintain a questioning attitude Critical thinking
Created by: nursekk