NURS191: Exam III - The Nursing Process
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Includes all the pertinent infomation collected by the nurse and other healthcare professionals.
Enables a comprehensive and effective plan of care to be designed and implemented for the patient.
The gathering of data about a specific problem that has already been identified.
A planned communication to obtain patient data
May be used by nurses to help patients identify potential and actual health risks.
Can also be used to explore the habits, behaviors, beliefs, attitudes and values which influence a patient's health.
Clearly identifies patient strengths and weaknessess, health risks and potential and existing health problems.
Observable and measurable information that can be seen, heard, or felt by someone other than the person experiencing it.
The examination of a patient for objective data that may better define the patient's condition and help the nurse in the planning of care.
The act of confirming or verifying data
The conscious and deliberate use of the five physical senses to gather information.
Compares a patient's current status to baseline data obtained earlier.
Guidelines for writing nursing diagnoses
Make sure the patient problem and etiology are linked by the phrase "related to".
Make sure the defining characteristics follow the etiology and are linked by the phrase "as evidenced by".
Write nursing diagnoses in legally advisable terms.
Groups of "cues" taken by the nurse which point to the existence of a patient health problem.
Which part of the following nursng diagnosis would be considered the etiology: Spiritual Distress related to the inability to accept the death of newborn child?
inability to accept the death of newborn child
Actual or potential health problems that can be prevented or resolved by independant nursing interventions.
Situations which are the primary repsonsibility of nurses.
Formed from a cluster of significant data
Why is the following nursing diagnosis incorrect: High Risk for Injury related to absence of restraints and side rails?
Use of legally inadvisable language.
Alternative diagnosis would be: Risk for Injury related to inattentive caregiver.
Why is the following nursing diagnosis incorrect: Sleep Pattern Disturbance related to insomnia?
Both clauses say the same thing.
Alternative diagnosis would be: Insomnia related to pain.
Why is the following nursing diagnosis incorrect: Alteration in Bowel Elimination: Constipation related to cancer of bowel?
Includes a medical diagnosis.
Alternative diagnosis would be: Constipation related to decreased peristalsis secondary to cancer of bowel.
Why is the following nursing diagnosis incorrect: Nausea and Vomitting related to medication side effects?
Identified problems are sign and symptoms.
Alternative diagnosis would be: Imbalanced Nutrition: Less than body requirements related to nausea and vomitting secondary to chemotherapy.
Evaluating a Goal
Each set of goals is derived from only one nursing diagnosis.
At lease one of the goals shows a direct resolution of the problem statement.
Each goal is brief, specific, phrased positively and specifies a time line.
The patient (and family) must agree with the goals.
The goals are supportive of the total treatment plan.
When should a nurse Validate?
When verifying a diagnosis.
Validate data and ask: Is my degree of confidence above 50% that other practitioners would formulate the same diagnosis?
Includes a problem r/t (related to) etiology.
Ex: Fluid volume deficient r/t decreased oral intake.
Short-Term vs. Long-Term Goals
Short- Term: Goals which can be achieved while the patient is in the hospital. Usually 24-24 hours in duration depending on the diagnosis.
Long-Term Goals: Usually outpatient goals. Can be one week or more depending on the diagnosis.
Prioritize Patient Problems based on:
- 1. Maslow's Hierarchy of Needs - Physological, Safety Needs, Love & Belonging, Self-Esteem & Self- Actualization.
- 2. Patient Preference - Comfort, ambulation, etc..
- 3. Anticipation of Future Problems - "Risk for" (Should NEVER be a priority diagnosis).
What are the approriate steps for the professional nurse if goals are not met?
After determining whether the goals were not met, partially met or met (with explaination) the professional nurse should make a judgement whether to terminate, continue or modify THE PLAN.
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