Nursing Process Word Scramble
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Question | Answer |
What do you do when creating a ND? | Identidy pt's strengths and health problems |
Patients will have.... | more than one diagnosis |
Diagnosis | "To distinguish" "To know" |
What is a Nursing Diagnoses? | Pt's, family or community actual or potential health problem that can be prevented or resolved |
Standard Nursing Diagnostis statements | ANA and NANDA |
Identifies diseases, physician directs primary treatment | Medical Diagnosis |
To write a ND you should | Analyze data Identify pt's strengths and weakness Validate info Identify actual and potential problems |
Nursing diagnoses describes... | problems withing the scope of independent nursing practice |
Relationship ND and Accountability | NS -> Clear identification of the body of nursing knowledge -> Greater accountability -> Greater professional autonomy |
Legal implications with ND | If you identify the problem, YOU must decide if you are qualify to treat it and will accept responsability. If not you are still responsible for getting help |
Actual ND | A problem that has been validated (Evidence) |
Potential ND | Risk. Diagnosis pt is vulnerable to or for |
Possible ND | Need Additional information |
Wellness ND | Critical judgement that validate a desired level of wellness. Needs two cues to be validated |
Sundrome ND | Comprise a cluster of diagnoses that may be present or potential for because of a certain event or situation EX. Rape trauma syndrome |
What should each ND contain? | Definition, Defining characteristics and related factors |
No problem | No nursing response indicated BUT reinforce good habits and patterns. Promote health |
Possible problem | Collect more date |
Actual or potential problem | Begin planning, implementing, and evaluating care to reduce, prevent or resolve problem |
What are strenghts? | Functions like cognitive abilities, coping skills, interpersonal strengths, and spiritual strengths |
Resources for strength | support people, adequate finances, healthy environment, mdecent health |
Health Problem | Person does not meet a standard of health or has limitation in an aspect of health status |
Example of ND | Acute Pain r/t tissue damange of right ankle and evidenced by crying, elevated VS, c/o pain 8/10, statements of "it hurts" |
Why do we use NANDA ND?? | to simplify and make diagnosis similar across the field. |
Planning | Establish pt's goals Identify priority ND Evidence based nursing intervention Document n communicate plan of care |
Why do nurses plan care? | Prevent, reduce or resolution of the problem and attainment of pts health expectations |
Outcome should | demonstrate progress or regression in improvement or resolution of pt's problem |
Outcome/Goals | Necessary part of planning phase |
Initial Planning | Developed by the nurse who performs the initial health history n physical assessment. Critical pathways used to plan care and individualized it to each individual |
Ongoing Planning | Carried out by any nurse. Adjusted and updated w/ pt's responses to intervention to keep plan current |
Discharge Planning | Best carried out by primary nurse or specialized nurse. Assure continuum of care |
How should you prioritize ND? | High - Greatest threat Medium - Not life threatning Low - Not related to problem |
Maslow's Law | 1. Physiologic needs 2. Safety Needs 3. Love n belonging 4. Self-esteem 5. Self-actualization |
Short term goals | Less than a week |
Long term goals | More than a week |
NOC | Opposite of problem. After finding diagnosis, make a statement and choose appropriate goals |
Short term should | support long term outcomes |
NOC should be written in verbs | describe, perform, verbalize, identify, reduce to, increase to, lose, gain, demonstrate |
Parts of NOC | Subject Verb Condition Criteria (how well will pt do) Time |
NOC Example | Pt will list a variety of five techniques that will avoid pain rising above a 4/10 within one week or by discharge |
Intervention | Actions that will help achieve goal |
Physician initiated intervention | Carrying out physicians prescribed orders |
Collaborative intervention | performed jointly by nurses n other healthcare team members EX. OT or PT |
Nurse initiated intervention | carried out by nurses w/o supervision or directing another healthcare member. EX. Turn pt q 2 h |
Structure care methodologies intervention | Nursing care is standarized (Critical pathways) |
Consultation Intervention | Nurses expand their nursing knowledge n discuss effective strategies |
NIC | What will nurse do to achieve goal. |
Always Always include | Teaching, learning opportunities |
Implementation | RN carries out plan of care by performing intervention and documentint, communicationg, collaborating, giving care. |
Delegate Nursing Care | Ethically and legally responsible for care when other help. Take frequent mini reports from unlicensed assistive personnel |
Evaluation | Evaluation of pt's achieved planned outcome (goal) |
Cognitive evaluation | Ask pt to repeat information or apply new knowledge |
Psychomotor evaluation | Ask pt to emonstrate new skill |
Affective evaluation | Observe pt's behaviors |
Physiologic evaluation | Perform physical assessment to evaluate physical changes in the pt |
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