Ch.4, (1-2)In Schuster
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Explain how nursing diagnosis is related to the rest of the nursing process?
- Nursing diagnoses overlaps with other nursing process steps.
- It begines during the assessment phase.
- It links the assessment step to all the step that follow it in the nursing process.
- Assessment data must be complete and accurate for you to make an accurate nursing diagnosis.
- Accuracy is essential becuase the nursign diagnosis is the basis for planning client-centered goals and inteventions.
- 2nd phase of the nursing process
- analyze your assessment data - The reasoning process used in interpreting assessment data.
- Using your ctritical thinking skills, you identify patterns in the data and draw conclusions about the client's health status, including strengths, problems, and factors contirbuting to the problems.
any condition that requires intervention to promote wellness or to prevent or treat disease or illness.
Differences between nursing diagnosis and a medical diagnosis
- Medical diagonsis: focus on disease and pathology
- Diagnose and treat disease
- Teach patient about treatment for their disease or injury
- MD desribes a disease, illness, or injury. Its purpose is to dentify a pathology so that appropriate treatment can be give.
- It is more narrowly focused than a nursing diagnosis .
- Nursing diagnosis: focuse on the patient's responses to illness
- Take a holistic approach
- Teach client's selfcare strategies increaseindependence indaily activities
- A formal diagnostic statement of the client's health status, containig both the problem and etiology(factors contributing to the problem)
- It is a statement of client health stastus that nurses can identify, prevent, or treat inependently. It is stated in terms of human responses (reactions) to disease, injury, or other stressors, and it can be either a problem or a strengths. Human responses can be biological, emotional, interpoersonal, social, or siritiual.
List the purposes of concept care maps
- Orgonizing patient data
- Analyze relatinships in the data
- Establish priorities
- Build on previous knowledge
- Identify what you do not understand
- Enable you to take a holistic view of the patient's situation
- Assist with critical thnking, analyzing clinical data, planning comprehensive nursing care for patients.
Describe how concept care mapping corresponds to the nursing process
- Before you can begin making a concept map you need to gather clinical data that is gathered during assessment of nursing process.
- Concept care mapping focuses strictly on real nursing care problems based on collected data. It does not focuse on potential problems.
- Concept mapping will help to make priority assessments that stil need to be performed regarding the primary reason for seeking care.
- Help to label nursing diagnosis
- Help to identify goals, outcomes and interventions.
- Help with evaluation in nursing process
Identify nursing standards of care for systematically gathering clinical data to construct a basic patient profile database
first standar of ANA involves the collection of data. Spacifically, the ANA states that collection of data about a patient's health status is to be systematic and continuous and that data must be accessible, recorded, and communicated.
Describe the essential componenets of a patient profile databse needed to develop a concept care map.
- Student name: to keep your data separate from other students
- Patient name: never write.
- Age, Growth, and Development: found on face sheet. Must be aware of the human growth and developmental tasks across the life span and than consider how a current health problem has affected the patients ability to accomplish the developmental tasks at hand. Use Eric H. Ericksons theory.
- Gender: Face sheet. Be aware of gender differences in communication and that you communicate crearly with both sexes.
- Admission data: Face sheet. good to know how long the person has been in the helth-care system.
- Reason for Hospitalization: Clearly tayped on face sheet without abbreviations.This is generaly a medical diagnosis
- Chronic illnesses: Face sheet. info on present and past chronic illnesses. Also found in the physician's history(as meidcal diagnoses) and progress notes, and nurse's initial intake history and physical assessment forms. Look up each chronic illness.
- Surgical procedures: Found on surgical consent forms.
- Advance Directives: admission nurse's assessment form and on Kardex
- Laboratory Data: specific section for the patient's labratory values.
- Diagnostic Tests: found under laboratroy and diagnostic proedures.
- Medications: Found on the medication sheet, and known as medication record, usualy kept in the same place as the Kardex. They are prescribed drugs, OTC, herbal remidies. know everything you need to know about each drgu you administer
- Allegies: meidcatin records and Kardex
- Pain Medications and Pain Ratings: in flow sheets and onthe nurses' notes.
- Treatments and Relation to Medical and Nursing Diagnoses (retional for treatment): Kardex. responsible fore ensuring that all tretment are deone. KNow the retional for each.
- Support Services: Kardex. represent all the discliplines involved in the patients' care.
- Consultations: are physicians who are specialists ex. caridologists. Kardex. Focuses on one body system.
- Types of Diet: Kardex. Diet restrictions. I&O found in nursess' notes or on the nursing flow sheets. Also will include any problems with nausea, vomiting, or diarrhea.
- Intravenous Fluids: type and rate of fluid administration will be found on the Kardex or in IV therapy records - looks similar to miedcation record. The presence of an IV means that the patient cannot take fluids, electrolytes, nutrients, or medications orally. Total amount of IV fluids given is recored on the nursing flow sheets under intake.
- Elimination: found on flow sheet and any abnormalities are found in the nurss' shift assessment notes.
- Activity: Kardex. Important to know what the patient can and cannot do regarding activities to keep her safe from injuires. KNow the percentage of weightbearing on the injured site. NWB - no weightbearing and WBAT - weightbearing as tolerated. Review fall assessment profile.
- ROUTINE PHISICAL ASSESSMENT
- writing only withing normal limits (WNL) or only anbormal finding is called charting by exception.
- Vital signs: BP, T, P, R
- Height and Weight: give info on basic nutritional status. Found in Nursing adminision assessment info
- Review of Systems: pg 42
- Neurological and Mental Status
- Muscuuloskeletal Status
- Cardiovascular system
- Respiratory System
- Gacstrointestinal System
- Skin and wounds
- Eyes, ears, nose, throat
- Psychosocial and Cultural assessments: pg 45
- Religous preference
- Marital status
- Health-Care benefits ans insurance
- Emotional status
are a special from of nurses' notes used to recrode routine observations.
page that is typed by the hospital registration dept.
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