Viv's Shenanigans Exam 1

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MLBuonarosa
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108470
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Viv's Shenanigans Exam 1
Updated:
2011-10-12 20:43:41
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Nursing process nursing diagnosis
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Stuff for exam 1
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  1. Characteristics of nursing process
    • 1. Systematic
    • 2. Dynamic
    • 3. Interpersonal
    • 4. Outcomes orientated
    • 5. Universally applicable
  2. Nursing Process: 5 key steps
    • 1. Assessing
    • 2. Diagnosing
    • 3. Outcome identification and planning
    • 4. Implementing
    • 5. Evaluating
  3. Assessment
    • Collect patient information from:
    • patient
    • previous shift
    • MD and othe provider notes
    • Family members
    • Observations and measurements
  4. Nursing diagnosis
    • Analyze patient data.
    • Identify health problems that independent nursing interventions can prevent or resolve
  5. Outcomes identification and planning
    • Individualize outcomes/goals for each nursing diagnosis
    • Develop with patient and family input
    • Ongoing (changes as patient status changes)
  6. Implementing interventions or plan of care
    • Nursing interventions are performed
    • AND all interventions are documented
  7. Evaluating
    Met, not met, partially met
  8. Outcome
    usually opposite of nursing diagnosis
  9. Kardex
    • synopsis of all patient orders
    • started at admission
    • written in pencil
    • not part of medical record
    • updated when new orders are written/every shift when there is a change
    • meds are usually listed separately
  10. Types of assessment
    • comprehensive
    • focused
    • emergency
  11. Cues
    • Part of assessment
    • subjective and objective data which are identified
    • may indicate that something is wrong
    • denotes "significant data"
    • deviates from standard or norm
  12. inference
    • part of assessment
    • judgement you reach about the cues
  13. NANDA
    • North American Nursing Diagnosis Assoc International
    • Nursing dx are not developed by NANDA
    • Review submissions for new dx, or revisions to existing ones or deletions
  14. Nursing (ANA's definition)
    the diagnosis and treatment of human response to actual or potential health problems
  15. Types of nursing diagnoses
    • Actual
    • Risk
    • Possible
    • Wellness
    • Syndrome
  16. Parts of a nursing diagnosis
    • Problem (diagnostic label, alphabetized in list)
    • Etiology
    • Defining characteristics (major and minor signs/symptoms)
  17. Actual Diagnosis
    • Problem
    • Etiologoy
    • Signs and symptoms
    • Nursing diagnosis (response to an illness)
    • Related to (something that the nurse can fix)
    • As evidenced by (proof or supporting assessment data)
  18. Risk for Dx
    • 2 parts (no "AEB")
    • Risk for "problem" related to ( )
  19. Goal vs outcome
    • Goal=big picture, an aim, an end; opposite of nursing diagnosis (e.g., patient will no longer be constipated)
    • Outcome=results achieved, more specific, measurable criteria (e.g., pt will have at least one soft formed stool within 8 hrs of taking laxative)
  20. Goals: long vs short
    • long term: usually more than one week
    • short term: hours or days
  21. Criteria for goals/outcomes
    • patient-centered
    • time-limited
    • measurable
    • realistic
    • relates directly to problem statement
  22. Cognitive outcomes
    • Describes increase in patient knowledge or intellectual behaviors
    • Patient will list
    • Patient will state
    • Patient will demonstrate
  23. Psychomotor outcomes
    • Describes patient achievement of new skills
    • By 10/22/11, the patient will correctly demonstrate application of wet-to-dry dressing...
  24. Affective outcomes
    • Describe changes in patient values, beliefs, and attitudes
    • By 10/3/11, the patient will verbalize valuing health sufficiently to practice new health behaviors..
  25. Implementation: Purpose
    • Assist pt to achieve valued health outcomes
    • Promote health
    • Prevent disease and illness
    • Restore health
    • Facilitate coping with altered functioning
  26. Maslow's hierarchy of human needs
    • Physilogic
    • Safety
    • Love and belonging
    • self-esteem
    • self-actualization
  27. Types of interventions
    • Independent: No MD order required (e.g., turning patient every two hours to avoid pressure ulcers)
    • Dependent: carrying out MD-prescribed order (e.g., administering an injection)
    • Interdependent: actions performed jointly by nurses and other healthcare team members
  28. Evaluation
    • Measure how well patient achieved desired outcome
    • Modify plan of care if indicated
  29. Possible results of evaluation
    • Terminate plan of care when outcomes achieved
    • Modify plan of care if outcomes not achieved
    • Continue plan of care if more time needed to achieve outcomes
  30. SBAR + R
    • Used for shift handoff and to communicate with MD
    • Situation: what's happening right now
    • Background: what is key clinical background leading up to this event
    • Assessment: what do you think might be going on (your analysiss)
    • Recommendation: What do you want done?
    • Response: What the MD/NP/PA will do. Agree on a what is to be done
  31. Incident report
    • Documents anything out of ordinary that causes harm to patient, staff or visitor
    • Do not put in medical record that an incident report was done
  32. Change of shift report
    • Summary of what
    • happened to patient during shift, what needs to be done
    • ◦Pending
    • tests, results of test
    • ◦Reports
    • of pain and last pain med given
    • ◦Any
    • meds or tx not given
    • ◦Any
    • wounds / dressings
    • ◦Mental
    • status
    • ◦Fall
    • status
    • ◦Poss.
    • discharge
  33. Charge nurse report
    • How
    • many patients on floor
    • ◦How
    • many staff members and designations
    • ◦How
    • many expected admissions/discharges
    • ◦Number
    • of isolation rooms
    • Number of
    • DNR patients
  34. Patient medical record
    • Legal document
    • confidential
    • permanent record of care received by patient
    • info recorded by several disciplines
  35. Late entry
    Someone else charted ahead of you

    • 10/06/09 pt. A&O
    • x3 . O2 at 3 l/m per NC. Chest CTA. N.
    • Nurse, RN

    0730 Late entry

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