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Flashcards in Identifying Clinical Problems in Nursing Practice 1 Deck (32):
1

What is nursing practice?

Problem solving approach to gather information/scientific data

2

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

3

Steps of nursing process?

1. assessment and diagnoses
2. planning
3. implementation
4. evaluation

4

assessment and diagnoses phase?

Collecting and analyzing assessment data in order to identify self-care deficits (nursing diagnoses)

5

planning phase?

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

6

implementation phase?

Carrying out planned nursing interventions

7

evaluation phase?

Judgement of the effectiveness of nursing care to meet patient goals:

Were the goals achieved?

8

Essential Elements of the Nursing Process?

Problem-oriented
Dynamic
patient-centered
Goal-directed
planned
creative
cyclic

9

purpose of data collection?

identify areas in which nursing intervention is required

directed to specific problems or needs

10

Types of Data Collected?

subjective data

objective data

self-care practices (SCP) data

lab/chart data

11

Techniques Used to Collect Data?

Interview
Physical Examination Techniques:

inspection-observe/look/smell
palpation-touch
percussion-tapping with hands
auscultation-listen with stethoscope

12

objective Data?

information about a person that can be perceived, measured or observed by another person.

Examples of objective data, temp., weight, appearance

13

subjective data?

info is reported by patient

Examples: pain, fatigue

14

SCP Data?

Information pertaining to the practices the patient would normally carryout in order to meet his/her self-care requisites.

15

lab/chart Data?

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.

16

Basic Conditioning Factors (BCF)?

age
sex
pattern’s of living
sociocultural orientation
developmental state
health state
family system factors
health care system factors

Part of collecting your data base

17

Making Inferences?

Your ability to identify cues and make inferences is influenced by:

your observational/assessment skills
your nursing knowledge
your nursing expertise

18

What is inference?

How you interpret or perceive a cue – the conclusion you draw about the cue – is called an inference.

ASSUMPTION

19

Validating Data?

ensure that assessment information is complete, accurate and factual

Eliminate any errors you may have

identify missing key information

20

When to validate data?

when data conflicts
patient seems odd/unusual

21

Clustering Data?

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

22

Action Demand?

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

23

How to write the ADS?

verb + USCR + in a + age + sex of the patient + story that makes it particular

24

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

25

Example –Action Demand

Action Demand Statement :
Decrease risk of injury in a 72 year old gentleman who is blind and experiences orthostatic hypotension.

Actions:
1) changing position slowly
2) changing position in stages
3) drinking 2-2.5 liters/day

26

Information in patient's data base?

Health problems and responses to these problems, name, age, sex, place of birth, family support system

27

Sources of data?

Client
Family/significant other
Health care team
Medical records

28

Methods for gathering data?

Interview
Physical examination

29

Techniques used when performing physical examination?

Inspection/smell
Palpation
Percussion
Auscultation
Vital signs
Height
Weight

30

What is data validation?

Compare data with another source of data to determine accuracy

31

Data organization involves?

Organizing data according to patterns and cues

32

Data clustering involves?

Set of signs and symptoms grouped together in a logical way