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