302-- Nursing Dx

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302-- Nursing Dx
2012-09-26 13:29:47
302 Nursing Dx

Exam 2
Show Answers:

  1. Method of caring that provides a framework for nursing practice
    Nursing Practice

    (it is Systematic, Patient-centered, and Goal Oriented)
  2. Steps to the Nursing Process
    • Assessment --> systematic & continuous
    • —Outcome Identification and Planning-->
    • Implementation
  3. Nurse and patient mutually identify expected outcomes and agree on nursing interventions necessary to meet these outcomes
    Outcome Identification & Planning
  4. —Nurse implements the plan of care, adapting it to each
    individual and documents nursing actions and patient responses
  5. —Nurse and patient
    Evaluate the effectiveness of the plan based on achievement of outcomes
    —Determine if the plan should be continued, modified, or terminated
  6. Who first used the term "nursing process"
    Hall (1955)
  7. Who published the first comprehensive book on nursing process. 
    Described 4 steps:  assessment, planning, intervention, evaluation 
    Yara and Walsh
  8. Who made nursing diagnosis a separate step in the process – leading to the 5 step process we use today.
    Gebbie and Lavin
  9. Steps to Nursing Process
    —Assess patient to determine the need for nursing care

    —Determine nursing diagnoses for actual and potential health problems

    —Identify expected outcomes and plan care

    —Implement the care

    —Evaluate the care
  10. Purpose of Nursing Diagnoses
    —Identify how an individual, group, or community responds to actual or potential health and life processes

    —Identify factors that contribute to or cause health problems (etiologies)

    —Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems
  11. Types of Nursing Concerns
    • *—Monitoring for changes in health status
    • *—Promoting safety and preventing harm, detecting and controlling risks
    • —*Identifying an meeting learning needs
    • —*Tailoring treatment and medication regimens for each individual
    • *—Promoting comfort and managing pain
    • *—Promoting health and a sense of well-being
    • *—Recognizing and addressing problems that impede the ability to be independent and live a healthy lifestyle
    • —*Determining human responses
  12. When was nursing dx introduced as a term
  13. ANA introduced nursing dx into professional nursing officially in
  14. North American Nursing Diagnosis Association (NANDA) came about in 
  15. What is the primary responsibility of nursing?
    • Collaborative problems
    • (—With collaborative problems the prescription for treatment comes from nursing, medicine, and other disciplines)
  16. Type of diagnosis that represents a problem validated by the presence of major defining characteristics.
  17. Type of diagnosis.... —clinical judgments that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation.
    Risk Dx
  18. Type of Diagnosis: ....statements describe a suspected problem of which additional data are needed.  Need more information to confirm or rule out the suspected problem.
    Possible Nursing Dx
  19. Type of Diagnosis....clinical judgments about an individual group or community in transition from a specific level of wellness to a higher level of wellness.  “Readiness for enhanced…”.
    Wellness Nursing Dx
  20. Type of Nursing Dx...—a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation:  “Rape-Trauma syndrome”
    Syndrome Nursing Dx.
  21. 3 Components to the Nursing Dx. Statement
    • —Problem
    • —Purpose to describe the health state or health problem
    • of the patient as clearly and concisely as possible
    • (—Use NANDA list (p. 274-275) and available in your PDA)
    • —Etiology
    • —Identifies the physiologic, psychological, sociologic,
    • spiritual and environmental factors believed to be related to the problem as either a cause or a contributing factor

    —The etiology directs the nursing intervention

    —For this semester…try NOT to use a medical diagnosis as your etiology

    • —Defining characteristics
    • —Subjective and objective data that signal the existence
    • of the health problem
    • **—Not required for a Risk for nursing diagnosis
  22. Problem Statements should be chosen from what list?
  23. Something that is desirable, useful:
  24. Theory of Human Needs comes from...
    Maslow's Hierarchy
  25. Maslows Hierarchy
  26. Factors that affect need satisfaction
    • acute/chronic illness
    • developmental stage
    • self concept
  27. Priortization of Needs:
    • Physiological Problems FIRST
    • Pyschological Problems Next
  28. How are Oxygen Needs assessed:
    • •HR
    • •LOC
    • •Mood
    • •Pulse Ox
    • •Resp. rate
  29. How do we assess a person's fluid status?
    • —Body wt
    • —Urine output
    • —Blood pressure
    • —Mucous Membranes
    • —Breath sounds
    • —Heart Rate, Resp. rate
    • —Skin turgor