Week 4: Introduction to Nursing Care Plans Flashcards
(23 cards)
What is the nursing process? (Potter and Perry 188)
Cognitive framework through which the nurse aims to identify, diagnose, and treat actual and potential health issues and challenges of patients from a holistic perspective
Includes…
- Assessment - collection of pt data
- Diagnosis - nurse analyzes pt data, create nursing diagnosis
- Planning - create individualized care plan
- Implementation - carrying out care plan
- Evaluation - evaluate pt outcomes
Assessment (Potter and Perry 188)
1st stage of the nursing process
Collection of a variety of different types of data pertinent to the patient’s health status or situation
Diagnosis (Potter and Perry 188)
2nd stage of the nursing process
The nurse analyzes the assessment data to determine key issues and make clinical judgements in the form of a nursing diagnosis, whereas the nurse will identify outcomes for the patient that are individualized to the patient and their current situation
This will direct the plan of care for the patient.
Planning (Potter and Perry 188)
3rd stage of the nursing process
Creation of a formal plan that prescribes strategies and alternatives to attain the expected outcomes
Implementation (Potter and Perry 188)
4th stage of the nursing process
Implementing the individualized care plan, may occur through coordinating care delivery, providing health teaching and health promotion activities to the patient, consulting with other health care providers, or providing medications or other therapies within the scope of practice of the RN
Evaluation (Potter and Perry 188)
5th stage of the nursing process
Conducting and evaluation of the patient’s response to the selected interventions and determining whether the interventions were effective
What is the role of the nurse during the assessment phase of the nursing process? (Potter and Perry 188)
Deliberate and systematic collection of data to determine a patient’s current and past health and functional status and to determine the patient’s present and past coping patterns
-Collection and verification of data from primary sources (pt), secondary sources (hcp, caregivers), and tertiary sources (literature, nurse’s experience)
-Analysis of all data as a basis for a nursing diagnosis, identifying collaborative problems, and developing a plan of individualized care
-Observes pt’s behavior, interviews pt and caregiver, conducts physical examination in a manner that elicits openness from the pt and integrates the nurse’s knowledge base and experience
-Asks questions and performs measurements based on the pt’s health history and nurse’s clinical knowledge
-Includes a nursing health history, picking up on inferences and cues, and collecting objective (physical exam, general survey) + subjective data (health history, family history)
-Making patterns and potential problem areas and solutions as nurse examines pt
What is the purpose of the nurse’s assessment in the nursing process? (Potter and Perry 188)
Establish an individualized database about the patient’s health status that includes their perceived needs, health challenges, and problems, and responds to these challenges or problems
What is the nurse’s role in the diagnosis phase of the nursing process? (Potter and Perry 196, Course Manual)
Form a diagnostic conclusion that determines the nursing care that a patient will receive
-Complex, patient-centered, collaborative activity, involving the HCT as well as information gathering and clinical reasoning to determine the goals of care for a patient’s major health problem
-Provide the basis for selecting nursing interventions to achieve outcomes for which nurses are accountable
-Using expert knowledge and critical thinking to assess a patient’s specific risk for these problems, identify the problems early, and then to take preventive action
-Analyzing clusters of data collected from the “assessment phase” and comparing them with consistent and normal patterns to consider various diagnoses that might apply to the patient
-Incorporating patient’s general health and needs into the nursing diagnosis
-Forming a carefully constructed nursing diagnosis/problem statement that describes the client’s health care issue, health risk, or opportunities for promoting health using assessment data, nurse’s knowledge from multiple ways of knowing, and nurse’s hypotheses as to what might be occurring in the situation
-Nursing diagnosis reflects nurse’s interpetation of the data, and helps nurse clarify and document what is happening, why it is happening, and how the nurse knows the issue is present
-Nursing diagnosis is dynamic and will change once the pt’s needs are met or new needs are identified
What is the purpose of the nurse’s diagnosis in the nursing process (Potter and Perry 202)
A mechanism for identifying the nursing care needed to address patient’s health problems, providing direction for the planning process and the selection of nursing interventions to achieve desired outcomes for patients , as well as communicating with other hcps of the patient’s health care issues
What is the difference between a medical diagnosis and a nursing diagnosis? (Potter and Perry 196, Course Manual)
Medical diagnosis - identification of a disease condition on the basis of a specific evaluation of physical signs and symptoms, the patient’s medical history, and the results of diagnostic tests and procedures; it is based on pathophysiology and usually remains constant
Nursing diagnosis - a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing; it is based on the client’s response to changes in health and can be dynamic
What are three types of nursing diagnoses/problem statements? (Course Manual)
- Diagnosis of an existing health care issue
“What is the issue” related to “the cause of the issue” as evidenced by “signs and symptoms you notice”
2.Diagnosis of a health risk - pt has risk of smt occuring, but it has not happened yet
“What is the issue” related to “the cause of the issue” (mention signs and symptoms if present)
- A health promotion or wellness diagnosis - pt (indiv, family, community) has motivation or desire to improve wellbeing
“What is the issue” as evidenced by “what you notic
What is the nurse’s role in the planning phase of the nursing process? (Potter and Perry 202)
Nurse set’s person-centered goals, outlines expected outcomes, plans nursing interventions, and prioritizes and selects interventions that will resolve the patient’s problems and achieve goals and outcomes
-Using critical thinking and deliberate decision making and problem solving to set priorities for a patient
-Collaborating with pt, caregivers, the HCT, and reviewing literature
What is priority setting in the planning phase of the nursing process, and how should priorities be set? (Potter and Perry 203, Course Manual)
Ranking of multiple nursing diagnoses or patient problems
considering…
-Immediate, life-threatening issues addressed first (ABCs)
-Client’s perception of what’s important
-Maslow Hierarchy of Needs
-Existing health care issues take priority over risk for issues
-Safety concerns
-Tackle an issue that may eliminate other issues
-Provide rationale to support your prioritization
What are goals and expecting outcomes in the planning phase of the nursing process, and how should goals be set? (Potter and Perry 203, Course Manual)
Specific patient behaviors or physiological responses that nurses set to achieve in the short term or long term through nursing diagnosis or collaborative problem resolution, providing a clear focus for the type of interventions necessary to care for the patient
Goals should be… (SMART-MP)
-Person centered - what the client will do/demonstrate
-Specific and Measurable - any nurse should be able to observe whether or not the goal has been met
-Attainable/Relevant - specific to the needs of the client, and reasonable for that specific client to achieve (assess resources available to client, what optimal functioning of the client can be expected to be)
-Time-bound - Goals should reflect the date or time by which the pt is expected to achieve the goals
-Mutuality - Work with client when setting goals, identifying timeline for meeting the goals, and identifying which goals are priorities
What are the 5 aspects of a nursing care plan? (Course Manual)
English
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- Nursing diagnosis (“What is the issue” related to “the cause of the issue” as evidenced by “signs or symptoms the nurse notices”)
-Rationale for diagnosis (Support significance of the issue, identifying why priorities were set the way they were, including literature to support rationale)
-SMART goal/Patient outcomes (SMART-MP, outcomes that indicate improvement or resolution of the nursing diagnosis)
-Interventions (Identify further assessment required and nursing actions to address the issue and reach the goal)
-Rationale for intervention (support interventions with evidence from research/literature)
What is Tanner’s model of clinical judgement? (Potter and Perry 296)
A model that brings all pieces of information together during a nurse’s care of a client
Includes…
Noticing - understanding key aspects of problem
Interpreting - turning observations into nursing action
Responding - Developing actions and implementation
Reflecting - Assessing response
Noticing (Potter and Perry 297)
1st stage of Tanner’s model of clinical judgement
Noticing what key aspects are being presented to more fully understand how each relates to actual observable signs and statements, considering what you already know of the situation and what more you need to learn to fully understand the situation in order to form a care plan.
Interpreting (Potter and Perry 297)
2nd stage of Tanner’s model of clinical judgement
Translating information obtained from collecting a client’s health history into meaningful nursing actions by reviewing client’s set goals , aspects identified during the noticing phase of the clinical judgement process, and literature + nursing experience.
Responding (Potter and Perry 298)
3rd stage of Tanner’s model of clinical judgement
Developing actions and planning implementation to address a client’s identified health and social issues through ongoing interaction and negotiations with the client
Reflecting (Potter and Perry 299)
4th stage of Tanner’s model of clinical judgement
Process of assessing a client’s response to care during provision of care (reflection-in-action) and following completion of care (reflection-on-action) while evaluating your work
Clinical judgement
The ability to make informed decisions about a patient’s care by using critical thinking, evidence, and an understanding of the patient’s condition
Clinical reasoning
Complex cognitive process that involves analyzing information about a patient to diagnose their problem and create a treatment plan.
Includes both the nursing process (ADPIE) and Tanner’s model of clinical judgement
