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Flashcards in Class 7-Nursing Process Deck (35)
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1
Q

Nursing process

A

framework for professional nursing practice/setting a standard of care

1
Q
A
2
Q

Standardized nursing language (NANDA North American nursing diagnosis association)

A

-defines nursing’s contribution and impact in healthcare. defines what nurses do
-gives nurses more evidence based outcomes and interventions
-easily integrated into EMR
-standardizes knowledge for nursing curriculum (QSEN)
-promotes nursing research

3
Q

think like a nurse to develop clinical judgement-why learn it?

A

-prepare for NCLEX
-transform thinking into clinical judgement
-become a self directed thinker
-becoming resilient
-reduce errors in healthcare setting

4
Q

NGN (next generation) clinical judgement measurement model

A

-recognize cues
-analyze cues
-prioritize hypotheses
-generate solutions
-take actions
-evaluate outcomes

5
Q

recognizing cues OR getting the information/assessing

A

-determine what information you need
-use multiple sources
-eliminate preconceived ideas
-scan the environment
-identify signs and symptoms
-assess systematically and comprehensively
-ensure that you collect accurate information

6
Q

alignment of the clinical judgement model and the nursing process

A

-CJM (clinical judgement model)
-nursing process

7
Q

CJM

A

-getting the information
-making meaning of the information
-determine actions to take
-take action
-evaluate outcomes and your thinking

8
Q

Nursing process

A

-assessment
-diagnosis
-planning
-implementing
-evaluating

9
Q

ADPIE-nursing process

A

Assessment

diagnosis (identify problem)(actual=3 part; risk=2 part)

planning (patient outcomes; nursing interventions)

implement

evaluation (patient outcomes)

LOOK AT SLIDE 8

10
Q

a nursing care plan allows the nurse to:

A

-INDIVIDUALIZE CARE that maximizes outcome achievement

-SET PRIORITIES

-FACILITATE COMMUNICATION among nursing personnel and colleagues

-PROMOTE CONTINUITY of high-quality, cost-effective care

-EVALUATE PATIENT RESPONSE to nursing care

-CREATE A RECORD used for evaluation, research, reimbursement, and legal reasons

11
Q

characteristics of nursing assessments

A

-purposeful
-prioritized
-complete
-systematic
-accurate
-relevant
-recorded in a standard manner

12
Q

Types of assessment

A

initial
-admission: in depth; set base line for hospitalization
-shift: baseline for shift; a bit quicker

focused

time-lapsed: coming back at certain time point; pre determined; after specific amount of time; usually more outpatient

13
Q

sources of data for assessment

A

-patient
-family and significant others
-patient record
-other healthcare professionals

14
Q

types of assessment data

A

subjective
-what the patient feels or says

objective
-measurable and observable

15
Q

how the phases of assessment set the stage for diagnosis

A

assessment
-collecting data
-identifying cues and making inferences
-validating data
-clustering related data and identifying patterns
-reporting and recording data
(identify a problem_

clinical reasoning
-(analyzing, synthesizing, reflecting, making judgements and drawing conclusions)

diagnosis

16
Q

diagnosis

A

nursing diagnosis: a clinical judgement about an individual’s responses to actual or potential health problems

nursing diagnosis provides the basis for selection of patient outcomes and the nursing interventions to achieve the set outcomes

17
Q

steps in diagnostic process

A

-create a list of suspected problems
-name actual and potential problems/diagnoses and clarify what is causing or contributing to them
-determine risk factors that must be managed for a risk DX
-confirm defining characteristics for an actual DX
-prioritize nursing diagnoses

18
Q

nursing diagnosis

A

-no problem
-problem focused diagnosis*
-risk diagnosis
*
-health promotion diagnosis
-syndrome diagnosis

***types of NSG DX used in the first semester

19
Q

actual problem 3 part nursing diagnosis

A

problem related to (r/t) etiology (cause or contributing factors) as evidence by (AEB) defining characteristics (subjective and objective data that support the problem you identified)

impaired nutrition less than body requirement R/T decreased desire to eat AEB BMI 13, Pre-albumin of 15 (norm 40-100), patient consumes only 5% of meals X 5 days

see slide 18

20
Q

etiology’s (cause of problem)

A

factors that appear to show some type of patterned relationship with the nursing diagnosis. such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. ONLY PROBLEM FOCUSED NURSING DIAGNOSES AND SYNDROMES MUST HAVE RELATED FACTORS.

21
Q

adding secondary to the etiology for clarification

A

pain r/t tissue damage 2ndary to MI AEB patient complaints of pain 8/10 substernal and pressure like, relieved with NTG

22
Q

actual nursing diagnosis-3 part statement

A

Problem; (drives patient outcomes)

R/T

Etiology (cause): (drives nursing interventions)

AEB

defining characteristics (s & s)

23
Q

at risk nursing diagnosis

A

-a clinical judgement concerning the vulnerability of an individual for developing an undesirable human response to health conditions or life processes (no defining characteristics)
-2 part diagnosis
-problem statement AEB risk factors
risk for falls AEB the following risk factors: previous history of falls

24
Q

risk factors

A

-environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, group, or community to an unhealthy event. only risk diagnoses have risk factors

25
Q

nursing diagnosis V medical diagnosis

A

-medical DX: myocardial infarction
-nursing diagnosis=response to the medical diagnosis (pain, fear, anxiety)
-pain r/t tissue damage AEB patients reports of substernal chest pain rated 10/10
-pain r/t tissue damage 2ndary to MI AEB patients reports of sub-sternal chest pain rated 10/10
-fear r/t hospitalization AEB patients statements “I’m afraid that I’m going to die”

26
Q

nsg dx versus medical dx

A

nursing diagnosis
-ineffective airway clearance
-disturbed body image
-risk for unstable blood glucose
-impaired urinary elimination
-self-care deficit: dressing

medical diagnosis
-pneumonia
-amputation
-type 2 diabetes mellitus
-post-op prostatectomy
-cerebrovascular accident

27
Q

Maslow’s hierarchy (how to set priorities)

A

-physiologic needs
-safety and security
-love and belonging
-self-esteem
-self-actualization

28
Q

physiologic needs

A

-oxygen
-food
-elimination
-temperature control
-sex
-movement
-rest
-comfort

29
Q

safety and security

A

safety from physiologic and psychological threat; protection, continuity, stability, lack of danger

30
Q

love and belonging

A

-affiliation
-affection
-intimacy
-support
-reassurance

31
Q

self-esteem

A

sense of self worth, self respect, independence, dignity, privacy, self reliance

32
Q

self-actualization

A

recognition and realization of one’s potential, growth, health, and autonomy

33
Q

benefits of nursing diagnoses

A

-individualizing patient care
-defining domain of nursing to health care administrators, legislators, and providers
-seeking funding for nursing and reimbursement for nursing services

34
Q

common errors

A

the problem and the etiology are the same
-altered comfort related to pain (incorrect)
-altered comfort related to tissue damage secondary to surgery