Flashcards in Final Review Deck (67)
Nursing Process: Assessment
Review of the clinical record
Review of the literature
Analyze data and draw conclusions.
Formulate hypothesis (“hunch”).
Cluster data in groups
Nursing Process: Diagnosis
Identify clusters of cues – compare clusters
Identify related factors
Document the diagnosis
Clinical judgment about client’s response to “actual” or “potential” health state
TYPES OF NURSING DIAGNOSES
Nursing Process: Planning
Document the plan of care
Identify expected outcomes
Individualize to the person
Realistic and measurable
Include a time frame
Review planned interventions
Schedule and coordinate total health care
Collaborate with other team members
Supervise implementation of care plan
Counsel person and significant others - teaching
Involve person in health care plan
Refer for continuing care
Document care provided
Refer to expected “outcomes”
Evaluate individual’s condition and compare actual outcomes with expected outcomes
Identify reasons for failure to achieve “expected” outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care
Evidence Based Practice (EBP)
SYSTEMIC APPROACH TO PRACTICE
EMPHASIZES “BEST EVIDENCE”
(RESEARCH BASED EVIDENCE)
COMBINES “BEST EVIDENCE” WITH…
are clinical judgments about a person’s response to an actual or potential health state
Health as absence of disease
Health and disease are opposite extremes on linear continuum
Disease is caused by specific agents or pathogens
A natural progression to health promotion and disease prevention rounds out our concept of health
Guidelines to prevention emphasize link between health and personal behavior
Continually moving toward “wellness”
MIND, BODY, SPIRIT = ONE ENTITY
Each part affects the others
HEALTH PROMOTION/DISEASE PREVENTION MODEL
Health and behavior are connected and inter-related”
NURSING MODEL “MIXTURE”
HEALTH PROMOTION/DISEASE PREVENTION
INCLUDES CULTURE, VALUES, FAMILY, SOCIAL ROLES, SELF-CARE BEHAVIORS, ETC.
Data Bases - 4 Types
1. Complete Data Base (complete history and physical examination)
2. Episodic or Acute Problem-Centered Data Base (focused assessment)
3. Follow-up Data Base (re-check)
4. Emergency Data Base (emergency assessment)
What is Culture
Culture is composed of all verbal and behavioral systems that transmit meaning
Culture is learned
Culture is shared
Culture is the result of adaptation to the environment
Culture is universal
Culture is dynamic
Becoming Culturally Competent
Other Support Systems
Principles of setting priorities
1. Airway problems
2. Breathing problems
3. Cardiac and circulation problems
4. Vital sign concerns (high fever)
Guide for cultural care
1. discover and understand your own heritage, cultural values, biases, and traditional health beliefs and practices.
2. Aquire basic knowledge of cultural values and health/health beliefs and practices for patient groups that you serve
Internal factors are those particular to the examiner, what you bring to the interview.
1. Liking Others
3. The ability to listen
Prepare the physical setting.
1. Ensure privacy
2. Refuse interruptions
4. Note taking
PURPOSE OF CLIENT/PATIENT INTERVIEW
Obtain a health history
Begin a relationship with the patient
Teaching and learning
One of the most important parts of health care process.
MEASURES TO RELIEVE ANXIETY AND CREATE CLIMATE OF TRUST
Behavior of interviewer important
Establish verbal contract
Emphasize therapeutic goals/purpose
Concentrate on “what the patient is saying”
Data gathering phase. Use of open and
closed ended questions.
Responses of the interviewer
Facilitation- Encourage the patient to say more such as nodding, saying go-on, continue, mmmk uh-huh.
Silence- use after open ended questions
Reflection- repeating what the patient said so that it shows that you were listening.
Empathy- an empathetic response recognises a feeling and puts it into words.
Clarification- Use this when a patients word choice is ambiguous or confusing. Example, tell me what you mean by...
Confrontation- this shifts the interview from the patients perspective to yours. (confrontation, interpretation, explanation, and summary)