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Functional ability assessment

- Important in discharge planning and home care
- future rehabilitation needs are derived from initial and ongoing assessment
- Joint commission requires for all patients

1

4 techniques used to obtain the primary objective data during the physical assessment

- Inspection (visual examination)
- Palpation (touch)
- Percussion (tapping the body surface)
- Direct auscultation (listening with the unaided ear)
- Indirect auscultation (listening with the stethoscope)

2

Subjective data

Info communicated to the nurse by the client, family or community

3

Objective data

Gathered through
physical assessment
laboratory
diagnostic tests

4

Primary data

-subjective and objective info obtained from the client
-what the client says or what you observe

5

Secondary data

Obtained secondhand from a
medical record
another caregiver

6

Comprehensive assessment

- provides holistic info about the clients overall health status
- enables you to identify client problems and strengths

7

Focused assessment

- performed to obtain data about an actual, potential, or possible problem that has been identified or is suspected
- Focuses on a particular topic, body part, or functional ability rather than on overall health status

8

closed question

yes, no, or short factual answers

9

Open-ended questions

- Specify a topic to be explored
- Are phrased broadly to encourage the patient to elaborate
- Ask when you want to obtain subjective data

10

Biographical data

- Unchanging info
- Responses reflect mental status of patient and ability to communicate
-

11

Past health history

- Includes childhood diseases, immunizations, previous hospitalizations, and previous surgeries
- Help guide your assessment

12

Diagnosis step of the nursing process

- A clinical judgment about individual, family, community responses to actual or potential health problems/life processes
- Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable for

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Nursing diagnosis

statement of client health status that nurses can identify, prevent, or treat independently

14

Medical diagnosis

- Describes a disease, injury, or illness
- Purpose to identify a pathology so that appropriate treatment can be given
- more narrowly focused then a nursing diagnosis

15

Collaborative problem

Certain physiological complications ( of disease, medical treatments, or diagnostic studies) that nurses monitor to detect onset or changes in status

16

NANDA was established in

1982

17

NANDA-1 was established in

2002

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Cluster cues

- Group of cues that are related to each other in some way
- May suggest a health problem
- To help ensure accuracy you should always derive a nursing diagnosis from data clusters rather than from a single cue

19

Prioritizing problems

- Places the problems in order of importance
- Does not mean you must resolve one problem before another

20

The 3 components of the PES system

Problem
Etiology
Symptoms

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P (Problem)

The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues

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E (Etiology)

Related to (r/t) phrase of etiology: related cause or contributor to the problem

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S (Symptoms)

Defining characteristics phase: symptoms that the nurse identified in the assessment

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Actual nursing diagnosis

- Describes human responses to health conditions/life processes that exist in an individual family or group, or community
- Supported by defining characteristics and related factors

25

Risk nursing diagnosis

- A clinical judgment about human experiences/responses to health conditions/life processes that have a high probability of developing in a vulnerable individual, family, group, or community
- Supported by risk factors

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Health-promotion nursing diagnosis

- A clinical judgment about a person's family's, groups's, or community's motivation and desire to increase well being and actual human health potential as expressed in the readiness to enhance specific health behaviors, which can be used in any health state

27

Related to (r/t) phase

- second part of the nursing diagnosis
- factors that appear to show some type of pattern relationship with the nursing diagnosis
- Enables the nurse to plan nursing interventions and refer for diagnostic procedures, medical treatments, pharmaceutical interventions, and others that will assist the client/family in accomplishing goals and return to state of optimum health

28

Defining characteristics phase

- 3rd part of the 3 part diagnostic system
- consists of signs and symptoms that have been gathered during the assessment phase
- The phrase as evidence by (aeb) may be used to connect the etiology
(r/t) with the defining characteristics

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6 standards of practice

Assessment
Diagnosis
Outcome identification
Planning
Implementation
- Coordination of care
- Health teaching and health promotion
- Consultation
- Prescriptive authority and treatment
Evaluation

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Function of the scope of practice

who
what
where
when
why
how

31

Advanced practice role

Masters or doctoral degree
Umbrella term for
- Certified registered nurse anesthetist (CRNA)
- Certified nurse midwife (CNM)
- Clinical nurse specialist (CNS)
- Nurse practitioner (NP, APRN, DNP)
Build on RN practice with
- Greater breadth and depth of knowledge
- Greater synthesis of data
- Increased complexity of skills and interventions
- Significant role autonomy

32

10 standards of professional performance

-Ethics
-Education
-Evidence based practice and research
-Quality of practice
-Communication
-Leadership
-Collaboration
-Professional practice evaluation
-Resource utilization
-Environmental health
-

33

Colorado Nurse Practice Act

-Revised 1 July 2010
Sets the requirements for:
- professional, advanced practice, and practical nurse licensure
- temp and volunteer licensure
Grounds for discipline

34

Code of Ethics
Provision 1

- Respect for human dignity
- Relationships to patients
- The nature of health problems
- The right to self determination
- Relationships with colleagues and others

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Code of Ethics
Provision 2

- Primacy of the patients interests
- Conflict of interest for nurses
- Collaboration
- Professional boundaries

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Code of Ethics
Provision 3

- Privacy
- Confidentiality
- Protection of participants in research
- Standards and review mechanisms
- Acting on questionable practice

37

Code of Ethics
Provision 4

- Acceptance of accountability and responsibility
- Accountability for nursing judgment and action
- Responsibility form nursing judgment and action
- Safe delegation of nursing activities

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Code of Ethics
Provision 5

- Moral self-respect
- Professional growth and maintenance of competence
- Wholeness of character
- Preservation of integrity

39

Code of Ethics
Provision 6

- Influence of the environment on moral virtues and values
- Influence of the environment on ethical obligations
- Responsibility for the healthcare environment

40

Code of Ethics
Provision 7

- Advancing the profession through active involvement in nursing and in healthcare policy
- Advancing the profession by developing, maintaining, and implementing professional standards in clinical, administration, and educational practice
- Advancing the profession through knowledge development, dissemination, and application to practice

41

Code of Ethics
Provision 8

- Health needs and concerns
- Responsibilities to the public

42

Code of Ethics
Provision 9

- Assertion of values
- The profession carries out its collective responsibility through professional associations
- Intra-professional integrity
- Social reform

43

Components of a goal statement

- Subject
- Action
- Performance criteria
- Target time
- Special conditions

44

NOC outcomes

- Outcome label
- Indicators
- Measurement scale

45

Individualized Nursing Care Plan

- Used to address nursing diagnosis unique to a particular client

46

Special Discharge or Teaching care plan

- May use standardized plan or include as teaching in a nursing diagnosis care plan

47

Computerized Care Plan

- Enter diagnosis or desired outcome
- Computer generates list of suggested interventions
- Choose appropriate interventions
- Individualize by typing in own interventions as needed