Unit 3 Exam 2 Nursing Process Flashcards Preview

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Flashcards in Unit 3 Exam 2 Nursing Process Deck (26):
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Lydia Hall

1955-introduce the term "nursing process"

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1973

Classification of the nursing process

ANA published Standards of Nursing Practice

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1989

Lynda Carpenito/ nursing dx

NANDA approval by ANA

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1982

North American Nursing Dx Association

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Components of the Nursing Process

Assessing
Diagnosing
Planning
Implementing
Evaluating

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Professional Benefits

defines scope of practice

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Nurse Benefits

allows professional growth
more effective in care/ more productive
--> collaboration

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Patient Benefits

Continuous, individualized, pt. centered care
Allows pt and family to participate

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Assessing

1st step of nursing practice
deliberate/ systematic/ holistic
identify current/ potential problems
utilizes therapeutic communication technology

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Purpose of Data Collection

Identify the Patient's.....
-present and past health status, coping patterns, and functioning status
-response to both medical & nursing treatments
-risk for potential problems
-desire for a higher level of wellness (always room for improvement)

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Subjective Data

pt's perception -- "what pt. tells you"
Symptoms/ covert

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Objective Data

Signs
Measurable

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Primary Source(s) of Data

Patient (pt)

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Secondary Sources of Data

Family/ Significant Other
Healthcare team
Health Records
Literature Review

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Data Validation

ensure accuracy of information
**BEST WAY is to Validate data directly with PATIENT**

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Cues

acquired via 5 senses
subjective & objective

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Inferences

nurses judgement/ interpretation of cues
very subjective
assign meanings to cluster of cues

***more cues/ more data--> increase potential judgements/ dx the more accurate your inferences*

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Actual Nursing Diagnosis

CLINICALLY VALIDATED by defining characteristics (signs & symptoms)
Comes from NANDA list

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3 Parts of the Nursing Dx

1. Problem (NANDA label) & Definition
2. Etiology ( R/T or Risk Factors)
3. Defining Characteristics ( Signs and symptoms)

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Risk Dx Definition (not that important)

Human Responses to health conditions life process that may develop in a VULNERABLE individual, family, or community. Supported by RISK FACTORS that contribute to increased vulnerability

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Risk Dx

Risk Factors GUIDE NURSING INTERVENTIONS to reduce or prevent the occurrence of the problem

2 Part Statement:No defining characteristics (s/s) b/c they represent POTENTIAL problems

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Health Promotion Dx

Readiness for ENHANCED

1 Part statement

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Nursing Dx

Describe Human Response NOT a Disease
Change from day to day
Tx by nurse (w/in scope)
May apply to alterations in individuals or GROUPS

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Collaborative Problems

physiological problem that nurse monitors and collaborates with medical team --> tx

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Planning

Third Step in Nursing Process

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3 Components of Planning Phase

1. Prioritize Nursing Dx
2. Develop Pt Goals
3. Plan Interventions