215 nursing process

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elevatedsound7
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215 nursing process
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2013-03-04 14:00:18
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215 nursing process
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215 nursing process
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  1. Difference between nursing process ad Medical Process
    • nursing
    • holistic focus
    • teach for independecnce
    • consult w/ medicine for treatment of disease
    • involved w/individuals, families, and groups
    • MEDICAL
    • disease focus
    • teach tx of disease
    • consults with nursing for planning ADLS
    • mostly involved with individuals
  2. diagnosing refers to
    the reasoning process
  3. nursing diagnosis is
    the problem statement consisting of the diagnostic label plus etiology
  4. actual diagnosis is
    • problem presents at the time of assessment
    • pesence of associated signs and symptoms
  5. risk diagnosis is
    problem doesnt actually exist but has risk factors
  6. Health promotion Diagnosis is
    • —Preparedness to implement behaviors to improve their health condition— 
    • Example: Readiness for enhanced Nutrition
  7. Wellness diagnosis is
    • Describes human responses to levels of wellness in an individual, family, or community— 
    • Example: Readiness for Enhanced Family Coping
  8. Syndrome Diagnosis is
    • Used when diagnosis is associated with a cluster of diagnoses— 
    • Examples:  Disuse Syndrome, Rape-Trauma Syndrome
  9. Components of A nursing diagnosis are
    • problem statement (clients response to the health problem)
    • etiology - CAUSE OF THE PROBLEM OR RISK FACTORS
    • as evidenced by statement
  10. defining characteristics are
    cluster of signs and symptoms THAT indicate the presence of a particular dagnostic label
  11. as evidenced by statement is
    • signs and symptoms
    • evidence that supprts that a diagnosis is present
  12. nursing diagnosis examples and all of the components
    • PAIN, ACUTE R/T EFFECTS OF SURGERY AS EVIDENCED BY PAIN RATED AS AN “8”, GUARDING OF INCISIONAL AREA, GRIMACING WHEN MOVING
    • CONSTIPATION R/T PROLONGED IMMOBILITY AS EVIDENCED BY NO BM FOR 5 DAYS, FEELINGS OF FULLNESS
    • NUTRITION,IMBALANCED:LESS THAN BODY REQUIREMENTS R/T DIFFICULTY SWALLOWING AS EVIDENCED
    • BY CHOKING ON FOOD, DECREASED INTAKE
    • NUTRITION, IMBALANCED:LESS THAN BODY REQUIREMENTS R/T ß APPETITE AS EVIDENCED BY EATING 10% OF EACH TRAY, STATEMENTS OF NO APPETITE
  13. tips for writing a good nursing diagnosis
    • Write it in respect to the patients response
    • Use R/t not Due To or any other wording
    • Write diagnosis in legally advisable terms
    • Write the diagnosis without a
    • value judgement
    • Avoid reversing parts
    • Be certain to avoid redundancy
    • Be clear and concise
    • Don’t put medical diagnosis in nursing diagnosis
    • Don’t rename a medical condition to fit nursing diagnosis
    • Don’t state 2 problems at the same time
  14. how to know which nursing diagnosis is correct
    • tells you problem
    • how do you treat that problem
  15. nursing diagnosis has to be something a nurse can ....
    • treat
    • ie NOT AIRWAY CLEARANCE, INEFFECTIVE  R/T CHRONIC PULMONARY DISEASE
    • BUT CORRECT = AIRWAY CLEARANCE, INEFFECTIVE R/T COPIOUS, VISCOUS SECRETIONS
  16. TIPS for writing outcomes/goals
    • Should be related to human response
    • Should be client centered- begin with “The client will…”
    • Should be clear and concise
    • Should be observable and measurable
    • Should be time limited
    • Should be realistic
    • Should be set together (nurse and patient)
    • OUTCOMES PROVIDE A BLUEPRINT FOR EVALUATION
  17. most importnat thing about outcomes is that
    it has a timeline and is measurable
  18. two types or nursing interventions =
    • dependent - need an order
    • independent - nursing function
  19. perfect time for ROM
    bed bath
  20. TIPS FOR WRITING INTERVENTIONS
    • Must be dated and signed in the clinical area
    • Use precise action verbs
    • Define who, what, where, when, and how often
    • Must be consistent with plan of care – every intervention must meet the outcome that has been set
    • Only one assessment order allowed
  21. most important about nursing order
    does it meet the outcome you set
  22. Items under the Diagnosing heading = AIF
    • analyze data
    • identify health problems, risks, and strengths
    • formulate diagnostic statements
  23. PES =
    • three part nursing diagnosis
    • Problem
    • Etiology (what is causing the problem)
    • Signs and Symptoms
  24. items under planning = PFSW
    • prioritize problems/diagnosis
    • formulate goals/desired outcomes
    • select nursing interventions
    • write nursing interventions
  25. what is important to remeber out pt with the same diagnosis
    even though they have same diagnosis they need a individualized care plan
  26. Five activities of the Implementing Phase
    RDISD
    • Reasses the client
    • determine the nurses need for assistance
    • implement the nursing interventions
    • supervise delegated care
    • document nursing activities
  27. Five activities of Evaluation
    CCRDM
    • collect data related to desired outcomes
    • compare data with desired outcome
    • relate nursing activities to outcome
    • draw conclusions about problem status
    • modify or terminate nursing care plan
  28. Nursing steps
    • Assessment
    • Diagnosis
    • Planning
    • Implementation
    • evaluation

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