Chapter 5 Flashcards
What is nursing ?
is the protection , promotion , and optimization of health and abilities , prevention of illness and injury , facilitation of healing , alleviation of suffering through the diagnosis and treatment of human response , and advocacy in the care of individuals , families , groups , communities , and populations
The nursing process ?
is a systematic method by which nurses plan and provide care for patients.
The defined assessment ?
as a systematic , dynamite way to collect and analyze data about a client, the first step in delivering nursing care.
Nursing process?
-Organizational framework for the practice of nursing
-Problem solving
-Six phases
-ANA Nursing Scope and Standards of Practice
Six phases of the nursing process ?
1.Assessment (Gather information about the patient’s condition )
2.Diagnosis (Identify the patient’s problems)
3.Outcomes identification (goal)
4.Planning (identify appropriate nursing action) 5.Implementation (Implement Perform the nursing actions identified in planning)
6.Evaluation (Determine if goals met and outcomes achieved)
Types of A cue date ?
is a piece or pieces of data that often indicate that an actual or potential problem has occurred or will occur
Subjective date ?
Subjective data is information that is provided by the patient .
Statements about nausea and descriptions of pain, fatigue , and anxiety are examples of subjective data .
Other terms for subjective data are symptoms and subjective cues .
Subjective data are hidden until shared by the patient.
Objective date ?
-Objective data are observable and measurable signs . For example , the LPN / LVN is able to observe capillary refill , measure a patient’s blood pressure , and observe and measure edema . Other terms for objective data are signs and objective cues
Types of data ?
Cue
Subjective
Objective
Sources of data ?
Primary source (the patient)
Secondary sources (Secondary sources include family members, significant others, medical records , diagnostic procedures, and previous nursing progress notes)
Methods of Data Collection?
Interviews ( Biographic data provide information about the facts or events in a person’s life - the health history , and the family history)
Physical exams allow the nurse to establish a database (a large store or bank of information ) for the patient.
A nursing diagnosis/patient problem statement is a type of health problem that can be identified by the nurse ?
-NANDA International
-Components
-Patient problems may be actual or potential
Patient problems NANDA-I ?
nursing diagnosis/patient problem statement
-is a type of health problem that can be identified by the nurse -“a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response , by an individual , family, group or community .
Components of a patient problem statement ?
-Patient’s presenting signs and symptoms Contributing ,etiologic ( causative), and related factors will write
- Defining characteristics are the clinical cues, signs, and symptoms that furnish evidence that the problem exists.
The cues, signs, and symptoms identified in the patient’s assessment are prefaced with “ as evidenced by” in the patient problem statement.
Patient problem statement may be actual or potentially ?-.
Acute problems are typically rapid in onset and are limited in the duration of time.
Acute problems can become chronic if the condition is not resolved. And
-If the patient’s condition is expected to change, add the phrase “ potential for” before the patient problem statement.
For example, it is reasonable to expect that a patient being prepared for surgery will experience pain, alteration in mobility , or the need for education . Therefore , a patient problem statement would be Potential for Discomfort . This problem or data
Actual patient problem statement ?
An actual patient problem statement identifies health-related problems that exist and are discovered during the nursing assessment.
-These health problems can be treated by the nurse
Potential patient problems are written as two part statements ?
(1 ) the patient problem statement with the adjective “potential “ in front of it, and (2 ) the risk factor
A medical diagnosis ?
is the identification of a disease or condition with evaluation of physical signs , symptoms , patient interview , laboratory tests , diagnostic procedures , review of medical records , and patient history .
Collaborative problems ?
are health-related problems that the nurse anticipates based on the condition or diagnosis of a patient .
Differentiating medical and nursing diagnoses ?
Although the patient is often able to recover from a medically diagnosed condition , the diagnosis does not change
-A patient problem statement may change or resolve as care is provided or the condition changes.
PATIENT-CENTERED GOALS?
- A patient- centered goal indicates the degree of wellness desired, expected, or possible for the patient to achieve
- Provides a description of the specific, measurable behavior the patient will exhibit in a given time frame
Planning ?
- The nurse establishes priorities of care and nursing interventions are chosen that will best address the nursing diagnosis
-Information is communicated through care plan so that all healthcare personnel will be directly involved in the care of the patient
-The nurse decides what interventions will be effective after working with the patient and significant others
PRIORITY SETTING?
-Nursing diagnoses are ranked in order of importance for the patient’s life and health
-Physiologic needs come before safety and security Safety and security needs come before love and belonging needs
—Life- and health
- threatening problems are ranked before other types of problems
Actual problems may be ranked before risk problems Priorities change as the patient progresses in the hospitalization ; as some problems are resolved, new ones can be addressed
Nursing interventions ?
Activities that promote the achievement of the desired patient outcome -Classified as physician-prescribed or nurse-prescribed
