Nursing Process/surgical patients NUR106

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Nursing Process/surgical patients NUR106
2015-12-20 11:57:13
Nursing process
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  1. Nursing process
    treatment of HUMAN RESPONSES key word for exam.
  2. Nurses
    • advocate 
    • promote healing-safety
    • challange status quo
  3. Human responses
    • reactions to an event or disease-everyone will react differently.
    • MI
    • physical-pain
    • psychosocial-fear of death
    • sociocultural-concerns about returning to work
    • spiritual response-bargaining with god..
  4. Human responses occur at different levels?
    • cellular
    • system
    • whole person
  5. knowledge base
    • physical/behavioral sciences
    • repertoire of intellectual, interpersonal and technical skills.
  6. OSBN nursing process
    systematic method RN use when providing care, assessing, nursing diagnoses, planning, intervening and evaluating.
  7. ANA
    • defines nursing process
    • authoritative statements
  8. 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
  9. Test question tip
    Assume the pt. is in perfect health unless they state otherwise in the question
  10. 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
  11. Holistic model
    • physiological
    • psychological
    • developmental
    • cultural 
    • sexual
    • spiritual
    • economic
    • learning
  12. nursing diagnosis
    educated and licensed to make nursing diagnoses: describes a patient (individual, family, or group) response to an actual or potential health problem.
  13. diagnosis steps
    • data analysis
    • problems ID
    • diagnostic labeling
    • prioritization
  14. problem identification
    My patient is....
  15. diagnostic labeling
    • NANDA label component-
    • Label/stem
    • related factors-contribute to the primary problem
    • defining characteristics-manifested by S&S associated with diagnosis
  16. Actual nursing diagnosis
    • 1. problem 
    • 2. etiology
    • 3. S&S
  17. Etiology
    • brief discription of the probably cause of the main problem-
    • holistic approach
  18. S&S
    The proof for the nursing diagnosis-problems, etiology
  19. 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%
  20. 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
  21. 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
  22. 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
  23. 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
  24. 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
  25. 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
  26. 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.
  27. Outcomes expected
    • ◦Subject: The patient will…
    • ◦Verb: Measurable action–For 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, feel–Example: “clear airways”
  28. 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.
  29. Test tip in regards to the treatments of a patient
    Assume that nothing has been done unless they tell you it has.
  30. PARQ Conference with patient
    • Procedure
    • Alternative treatments
    • Risks of procedure
    • Questions
  31. Informed consent
    • 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.
  32. drains and time frames
    • Sansuinous onset-24
    • serosanguinous 24-72
    • serous over 72 hours. 
    • anything other than red/pink it's more likely purulent.
  33. 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.