Flashcards in Solving Clinical Problems in Nursing Practice Deck (33):
steps of nursing process?
1. assessment & diagnosis
Data Collection methods?
Basic tool of communication
Review of the chart
Clustering the data into meaningful patterns involves:
Recognizing cues and making inferences
Collecting/identifying data that supports your preliminary conclusion.
Generating an Action Demand.
Identification of Self-Care Deficits?
No self-care deficit:
Self-care ability = action demand
Self-care ability > action demand
Self-care Deficit with need for nursing intervention:
Self-care ability < action demand
Components of a SCD Statement?
State the actual or potential inability to meet the specific self-care demand.
State the specific limitations of your patient
“Inability to ACTION DEMAND STATEMENT related to limitations in POWER COMPONENTS.”
10 Power components: knowledge-skills-motivation?
1. Required knowledge or ability to acquire knowledge re: actions/steps
2. Motivation for each actions/steps
3. Attention span for each action/step
4. Physical energy for each action/step
5. Control of the body position for each action/step
6. Ability to reason for each action/step
7. Ability to make best decisions for each action/step
8. Repertoire of skills to be able to perform actions/steps
9. Ability to adjust self-care priorities to include actions/steps
10. Consistently perform steps/actions to integrate in one’s life
Example of SCD statement?
inability to reduce falls in a 60 y.o. male who has colon cancer and is undergoing chemotherapy, had diarrhea and vomiting due to a limitation :
inability to make best decisions for himself
inability to control body position
phases of planning?
1. Establish priorities among the SCDs
2. Determine desired outcomes based on the SCD statement.
3. Plan interventions (orders) to achieve these outcomes.
4. Communicate the plan of care.
Guidelines for Establishing Priorities?
Maslow’s Hierarchy of needs:
- Those essential for the maintenance of all life processes.
- Those that prevent personal harm or injury.
- Those that maintain health.
- Those that contribute to the state of human well-being.
Nursing outcomes or goals of nursing need to be?
Measurable and time-limited
types of goals?
A specific, measurable behaviour or response reflecting client’s highest possible wellness level and independence of function
Short term goal?
An objective client behaviour or response expected within hours to a week
Long term goal?
An objective client behaviour or response expected within days, weeks, or months
Sample long term goal for M. counts?
regain initial wt of --- kg in 4 weeks as evidenced by:
pt will reduce # of bm to 2/day
Determine Desired Patient Goals?
Broad overall statement that describes an expected conclusion to a patient problem.
Should be clearly connected to the SCD you have identified.
Will be similar to your action demand statement but more specific because you can make reference to your client’s self-care ability or limitations thereof.
Should start with the words “patient will” as the goal should be patient centered.
Expected outcomes for goals?
Specific, measurable changes in a client’s status
Provide focus or direction
Determine when a specific client-centered goal has been met
types of outcomes for goals?
describe increased patient knowledge or intellectual behaviours.
EX: GOAL: Patient will develop basic knowledge of healthy weight loss diet as evidenced by:
Correctly lists at least 5 high sugar content foods to avoid by discharge.
Correctly identifies high fat content foods in his diet by discharge.
describe the patient’s achievement of a new skill.
EX: GOAL: Patient will develop adequate skills in order to be able to carry out the prescribed insulin treatment as evidenced by:
Demonstrates proper technique for accurate drawing of insulin into the syringe by discharge.
Demonstrates correct technique for insulin injection at the end of the teaching session.
describe changes in the patient’s values, beliefs and/or attitudes.
EX: GOAL: Patient will verbalize valuing the health sufficiently to change nutritional plan for weight loss as evidenced by:
Verbalizes the benefits of low fat diet by the end of the course
Verbalizes the need for maintaining lifetime dietary changes by the end of Novemeber.
describe changes in patient’s physical state
EX: GOAL: Pt will regain baseline defecation pattern as evidenced by:
Soft stool q day by the end of the week
No pain on defecation by the end of the week
Guidelines for Writing Expected Outcomes?
Setting a Goal and Expected Outcomes for Mr Counts
Patient will use strategies to prevent falls during hospitalization
as evidenced by:
Getting out of bed slowly with assistance by Nov.20
Returning to a supine position when dizzy by Nov.20
Transferring from bed to commode by pivoting by Nov.20
Walking only when supervised until strength improves by Dec. 5th.
Other examples of goals and expected outcomes
Student will successfully pass nursing 180-111 as evidenced by:
Obtaining 60% total on all tests (CT1, CT2 and final) at the end of the semester
Obtaining 60% on Q0 questions on final exam
Obtaining “Meets expectations” for all performance criteria on clinical evaluation tool at the end of the semester
Patient will maintain adequate ventilation as evidenced by:
RR 12-20 bpm by …(date)
O2 sat of 95% or higher on room air by…(date)
Effortless breathing by….(date)
A nursing intervention is any treatment that a nurse performs to enhance the patient’s condition.
Knowledge required by the nurse to determine the nursing actions includes?
Knowledge of the patient.
His/her abilities and limitations for self-care.
Theoretical knowledge of what is required.
Based on research and understanding of:
The courses of action required to resolve the SCD(s).
How these actions work (scientific rationale)
Types of Interventions?
Action based on scientific rationale that a nurse executes.
Actions are performed to:
Monitor health status
Resolve, prevent or manage a problem
Facilitate independence or assist with ADL
Promote optimal sense of physical, psychological and spiritual wellbeing
Do not require a physician’s (or other team member’s) order.
RESOLVE OR MANAGE A PROBLEM
MONITOR HEALTH STATUS
ASSIST WITH ADL'S
An intervention carried out by a nurse in response to a doctor’s order (delegated act)
Nurse will start, monitor and maintain IV fluids in response to a medical order.
Interventions initiated by other members of the team that require the knowledge, skills and/or judgement of the nurse to carry out.
Nurse administers pain medication that is ordered PRN based on her assessment of pain.