Nursing Process/surgical patients NUR106
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treatment of HUMAN RESPONSES key word for exam.
- promote healing-safety
- challange status quo
- reactions to an event or disease-everyone will react differently.
- psychosocial-fear of death
- sociocultural-concerns about returning to work
- spiritual response-bargaining with god..
Human responses occur at different levels?
- whole person
- physical/behavioral sciences
- repertoire of intellectual, interpersonal and technical skills.
OSBN nursing process
systematic method RN use when providing care, assessing, nursing diagnoses, planning, intervening and evaluating.
- defines nursing process
- authoritative statements
6 steps nursing process
- assessing: systemic collection of data
- diagnosis: data analysis, bases on present illness, problem identification, formulate nursing diagnosis
- outcome identification: what the pt. is expected to acheive
- planning: holistic plan of care-to achieve outcomes.
- implementation: execute nursing care plan
- evaluation: Pt level of outcome achievement
Test question tip
Assume the pt. is in perfect health unless they state otherwise in the question
PN vs RN
RN does everything a PN will do in regards to a focussed assessment, but will go through a comprehensive assessment as well -extensive collection and analysis of data for assessment. Holistic approach
educated and licensed to make nursing diagnoses: describes a patient (individual, family, or group) response to an actual or potential health problem.
- data analysis
- problems ID
- diagnostic labeling
My patient is....
- NANDA label component-
- related factors-contribute to the primary problem
- defining characteristics-manifested by S&S associated with diagnosis
Actual nursing diagnosis
- 1. problem
- 2. etiology
- 3. S&S
- brief discription of the probably cause of the main problem-
- holistic approach
The proof for the nursing diagnosis-problems, etiology
Impaired skin integrity nursing diagnosis
- Related to-etiology-physical immobility, low O2 sat, incontinence
- S&S-manifested by disruption of the skin surface, bed rest, urinary incontinence and absent breath sounds in RL lung field, productive cough, with thick green mucous, RR-25, SA02 of 88%
Ineffective airway clearance
- eitology: increased production of secretion and increased viscosity secondary to pneumonia
- Manifested-S&S: course crackles, all lung fields, productive cough w/ thick green expectorant, increased RR >20
Priority in the nursing process- Maslows Hierarchy of needs
Priority One: Physiological Needs◦Problems interfering with ability to be free of offensive stimuli.Pain, nausea, physical irritation
Maslows Priority 2
- Priority Two: Safety and Security Needs◦
- Problems posing a threat to safety and security.Anxiety, fear, environmental hazards, physical activity deficits, violence toward self or others, knowledge deficit
Maslows priority 3
- Priority Three: Love and Belonging Needs◦
- Problems posing a threat to feeling loved and a part of something.Loss of a loved one, sensory-perceptual losses, inability to maintain family and significant other relationships, isolation
Maslows priority 4
Priority Four: Self-Esteem Needs◦Problems posing a threat to self-esteem.Inability to perform activities of daily living, change in structure or function of a body part
Maslows priority 5
Priority Five: Self-Actualization Needs◦Problems posing a threat to the ability to achieve personal goals.Inability to return to school, negative personal assessment of life events
Outcome Ineffectve airway clearance
Nursing expected outcome: The Patient will have clear airways throughout all lung fields by discharge as evidence by absence of crackles, productive cough and respiratory rate less 20.
- ◦Subject: The patient will…
- ◦Verb: Measurable actionFor example: Identify, Describe, Discuss, Relate, State, List, Verbalize, Demonstrate, Has an absence of, Perform, Walk, Stand, Sit
- Samples of Non-measurable verbs: know, understand, appreciate, think, accept, feelExample: “clear airways”
Nursing diagnosis example
Impaired gas exchange related to infectious exudate and fluids in the airways of the lung secondary to pneumonia manifested by respiratory rate > 20, can only speak 3-4 words before gasping for a breath, unable to lay flat, pulse oximeter readings 88%, productive cough with bright green expectorant.
Test tip in regards to the treatments of a patient
Assume that nothing has been done unless they tell you it has.
PARQ Conference with patient
- Alternative treatments
- Risks of procedure
- Married at 16
- Emancipated minor
- any 15 year old or older may consent for hospital care, medical diagnosis, dental daignosis/treatment, surgical diagnosis/treatment, providers may advise parents about care, treatment, diagnosis.
drains and time frames
- Sansuinous onset-24
- serosanguinous 24-72
- serous over 72 hours.
- anything other than red/pink it's more likely purulent.
Consent is always prefered, but not required for treatment
- family member may give consent over the phone-must have 2 witnesses
- two physicians may provide authorization if POA unavailable.
- court can appoint a legal guardian-when no family available
- patients who cannot sign can sign an X must be witnessed by 2 providers
- ESL must have certified interpreter.
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