Flashcards in Identifying Clinical Problems in Nursing Practice 1 Deck (32):
What is nursing practice?
Problem solving approach to gather information/scientific data
The primary purpose of the nursing process?
to assist nurses to manage patient care in a scientific and creative manner
Based on the scientific problem solving method
Steps of nursing process?
1. assessment and diagnoses
assessment and diagnoses phase?
Collecting and analyzing assessment data in order to identify self-care deficits (nursing diagnoses)
Designing plan of care that is tailored to the patient’s problems:
How to prevent, reduce, resolve problems
how to implement nursing interventions
How to support patient’s self care abilities
Carrying out planned nursing interventions
Judgement of the effectiveness of nursing care to meet patient goals:
Were the goals achieved?
Essential Elements of the Nursing Process?
purpose of data collection?
identify areas in which nursing intervention is required
directed to specific problems or needs
Types of Data Collected?
self-care practices (SCP) data
Techniques Used to Collect Data?
Physical Examination Techniques:
percussion-tapping with hands
auscultation-listen with stethoscope
information about a person that can be perceived, measured or observed by another person.
Examples of objective data, temp., weight, appearance
info is reported by patient
Examples: pain, fatigue
Information pertaining to the practices the patient would normally carryout in order to meet his/her self-care requisites.
Information from the patient’s chart including:
Blood work results
Results of diagnostic tests
Consults/note from other members of the health care team.
Information from progress notes.
Basic Conditioning Factors (BCF)?
pattern’s of living
family system factors
health care system factors
Part of collecting your data base
Your ability to identify cues and make inferences is influenced by:
your observational/assessment skills
your nursing knowledge
your nursing expertise
What is inference?
How you interpret or perceive a cue – the conclusion you draw about the cue – is called an inference.
ensure that assessment information is complete, accurate and factual
Eliminate any errors you may have
identify missing key information
When to validate data?
when data conflicts
patient seems odd/unusual
Organizing your data using the tools from orem’s model helps you to cluster your data
No tools do all of the clustering you need to do to understand and identify every problem.
You need to think about the relationships among the pieces of data and among the self-care requisites
Analyze all of the information and draw a conclusion regarding the situation.
This involves the generation of an action demand related to the self-care requisite of concern.
Consists of these two components:
1) action demand statement (ADS) (synthesis statement)
2) actions to be taken
How to write the ADS?
verb + USCR + in a + age + sex of the patient + story that makes it particular
Action demand; actions to be taken
Actions to be taken:
What needs to be done to meet the goal described in the synthesis statement.
Should be based on sound scientific rationale
Example –Action Demand
Action Demand Statement :
Decrease risk of injury in a 72 year old gentleman who is blind and experiences orthostatic hypotension.
1) changing position slowly
2) changing position in stages
3) drinking 2-2.5 liters/day
Information in patient's data base?
Health problems and responses to these problems, name, age, sex, place of birth, family support system
Sources of data?
Health care team
Methods for gathering data?
Techniques used when performing physical examination?
What is data validation?
Compare data with another source of data to determine accuracy
Data organization involves?
Organizing data according to patterns and cues