Fundamentals of nursing/ Nursing Roles

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  1. Validation
    Compare data to see if it is accourate
  2. Subjective Data
    what the patient states, verbal descriptions about the patients health status
  3. Review of symptoms (ROS)
    a systematic approach for gathering the patient’s self-reporting data on all body systems.
  4. Open ended questions
    Prompt the patient to describe the situation in more than one or two words.
  5. Objective Data
    Observations or measurements of a patients health status.
  6. Nursing Process
    critical thinking process that nurses use to apply critical thinking. Process that professional nurses use to apply the best available evidence to care giving and performing human functions and responses to health and illness.
  7. Nursing Health History
    gathered during the initial or early assessment of the patient. The history is a major component of the assessment.
  8. Inference
    is a judgment or interpretation of cues.
  9. Functional health pattern
    Gardens model of 11 patterns; a practice of standards that provides categories of information for the assessment
  10. Database
    Store or bank of information, especially in a form that can be processes by a computer. Information about the patient’s perceived needs, health problems, and responses to their problems.
  11. Cue
    Information obtained through the use of symptoms
  12. Concomitant symptoms
    Symptoms that a patient experiences along with the primary
  13. Closed end questions
    questions that limit answers to one or two words. Yes, No questions
  14. Back channeling
    Active listening, using prompts that indicate that you have herd and are interested inn hearing the whole patent story. This encourages patients to give more details.
  15. Assessment:
    the deliberate and systematic collection of information about a patent to determine his or her current or past health and functional status and present and past coping patterns.
  16. Successful interpretation and validation of assessment data
    ensure that you have collected a complete database.
  17. When collecting a complete nursing history
    let the patient’s story guide you in fully exploring the components related to his or her problems.
  18. It is easier to explore cultural differences
    if you allow time for thoughtful answers and ask your questions in a comfortable order.
  19. During an assessment
    interview encourage patients to tell their stories about their illnesses or health care problems.
  20. The best clinical interview focuses on
    the patient, not your own agenda
  21. An initial patient-centered interview involves
    (1) setting the stage, (2) gathering information about the patient’s problems and setting an agenda, (3) collecting the assessment or a nursing health history, and (4) terminating the interview.
  22. A successful interview requires preparation
    including reviewing all available information about the patient, preparing the interview environment, and timing to avoid interruptions.
  23. In a patient-centered interview
    an organized conversation with the patient allows the patient to set the initial focus and initiate discussion about his or her health problems.
  24. During assessment
    critically anticipate and use an appropriate branching set of questions or observations to collect data and cluster cues of assessment information to identify emerging patterns and problems.
  25. Once a patient provides subjective data
    explore the findings further by collecting objective data.
  26. There are two approaches to gathering a comprehensive assessment:
    use of a structured database format and use of a problem-focused approach.
  27. Assessment involves
    collecting information from the patient and secondary sources (e.g., family members) along with interpreting and validating the information to form a complete database.
  28. is a variation of scientific reasoning that involves five steps: assessment, nursing diagnosis, planning, implementation, and evaluation.
  29. SMART goals
    • Specific
    • Measurable
    • Approprate
    • Realistic and
    • Timely
  30. ADPIE is an easy acronym used to remember the steps of the nursing process:
    A= assessment data, perform the nursing process
D= make a nursing diagnosis -using PES Problem, etiology, symptoms.
P= plan - formulate and write out comes/ gaol statements and determine approprite interventions based on evidance. EBN
   I= implementation of care - giving care 
E= evaluation of care- revise care make sure it is working
  31. There are five sequential steps to the process.
    1 Defining a specific clinical question
2 Finding the best evidence that relates to the question
3 Determining if the study results are true and applicable to the patient
4 Integrating patient values and clinical experience with the evidence to make conclusions
5 Evaluating the impact of decisions through determination of patient outcomes
  32. 3 problem solving methods used by Nurses
    • Nursing Process

    • EBN

    • quality-control
  33. Nursing diagnosis labels 5 choices
    Actual Nursing Diagnosis -
2.Risk Nursing Diagnosis
3.Health-Promotion Nursing diagnosis
4.Wellness Diagnosis
5.Syndrome Nursing Diagnosis
  34. A patient is being discharges after surgery, the incision is healing well with no signes of redness or irritation. Following instructions, the patient has demonstrated effective care of the incision, including cleaning the wound and applying the appropriate dressing for correctly to the wound. These behaviors are an example of?
    An expected outcome is an end result that is measureable, desirable, observable, and translates into observable patient behaviors. It is a measure that tells you if the educational interventions led to successful goal achievement, the patient’s self-care of the wound. An evaluative measure would be the process of observing the patient. Reassessment is a behavior performed by the nurse. The type of wound cleanser and dressings would be a standard of care.
  35. The nurses evaluates a patent who has a loss of appetite, has lost 15 lbs in the last 2 months, she shows signs of depression and doesn’t seem to understand what foods are healthy for her. The Nursing diagnosis of imbalanced nurturance; less than body requirements related to reduced intake of food and a goal of “ Patient will return to base line in 3 months”, which is the appreciate outcome?
    With the related factor of reduced intake of food, the outcomes should focus on behaviors that reflect an increase in intake. Thus achieving an increase in calories and an improved appetite for food would be appropriate. The patient’s depression probably contributes to the loss of appetite, but being able to discuss the source of depression is not an outcome for improving her baseline weight. Being able to identify protein sources would improve any knowledge deficit the patient might have but would not help her gain weight.
  36. Reassessment of all patient factors relating to the nursing diagnosis and etiology is necessary when modifying the care plan.
    Redefining nursing diagnosis; after reassessment determines which nursing diagnosis is accurate for the situation. Determine if you selected the correct diagnosis and if the etiological factor is correct. Goals and expected outcomes; when revising a care plan decide if the goals and expected outcomes are still appropriate. Reevaluate interventions requires two factors: The appropriateness of the intervention The correct application of the intervention
  37. Care Plan Revisions;
    each time you evaluate the patent you decide if the care plan needs discontinued or revised. If the patients needs have been meet, goals are successfully meet, discontinue related portion of care plan. Modification of the care plans; when goals are not meet you identify the factors that interfere with their achievementChanges in the patient’s condition, needs, or abilities make altering the care plan necessary.
  38. To objectively evaluate the degree of success inn achieving outcomes of care, perform the following steps:
    Examine the outcome criteria to identify the exact desired patent behavior of responses. Evaluate the patent’s actual behavior or responses. Compare the established outcome criteria with the actual behavior or response. Judge the degree of agreement or only partial agreement between the outcome criteria and the actual behavior or response. If there is not agreement or potential agreement between the outcome criteria’s and the actual behaviors or response, what is/ are the barriers? Why did they not agree? Document results; documenting accurate information is an important part of evaluating, outcomes. This is needed for the patient’s medical record. When documenting a patents response to your interventions, describe the interventions, the evaluative measures used, the outcomes achieved and the continued plan of care.
  39. Collaborative and evaluate effectiveness of interventions
    collaboration is an important part of patent centered care. A Nurse must respect the patent and family as a core member of the health care team, measuring that the patent and family must be actively involved in the evaluation process.
  40. An expected outcome
    is an end result that is measurable, desirable, and observable and translates into observable patient behaviors. It is a measure that tells if the intervention applied in patent care lead to successful goal achievement.
  41. Criterion- Based Evaluation;
    You evaluate nursing care by knowing what to look for as described in the criterion- based standards included in a patents goals and expected outcomes. The goal and outcome are objective criteria needed to judge a patents response to care.Goals; is the expected behavior or response that indicates resolution of a nursing diagnosis or maintenance of a healthy state It is a summary statement of what will be accomplished when a patent has met all expected outcomes.
  42. Standard of Care
    is a minimum level of care acceptable to ensure high quality of care to patients. Standard of care define the type of therapies typically administered to patients with defined problems or needs.
  43. Nursing Sensitive Outcomes
    is a measurable patient or family state, behavior or perception largely influenced by and sensitive to nursing interventions.
  44. Evaluative measures
    evaluation a persons response to nursing care requires the use of evaluative measures which are assessment skills and techniques, (Observations, Physiological measures, patent interviews)
  45. Evaluation,
    The final step of the nursing process, is critical to determine whether, after applying the nursing process the patents condition or well being improved.
  46. Evaluation examines two factors:
    the appropriateness of the interventions selected and the correct application of the intervention.
  47. A patient’s nursing diagnoses
    priorities, and interventions sometimes change as a result of evaluation.
  48. Documentation of evaluative findings
    allows all members of the health care team to know whether or not a patient is progressing.
  49. When interpreting findings,
    you compare the patient’s behavioral responses and physiological signs and symptoms that you expect to see with those actually seen from your evaluation and judge the degree of agreement.
  50. It sometimes becomes necessary to collect evaluative measures over time to determine if
    a pattern of change exists.
  51. Evaluative measures are assessment skills or techniques that
    you use to collect data for determining if outcomes were met.
  52. Criterion-based standards for evaluation are the
    physiological, emotional, and behavioral responses that are a patient’s goals and expected outcomes.
  53. Positive evaluations occur when
    you meet desired outcomes and they lead you to conclude that your interventions were effective.
  54. During evaluation apply critical thinking
    to make clinical decisions and redirect nursing care to best meet patient needs.
  55. Evaluation is a step of the nursing process that includes two components
    an examination of a condition or situation and a judgment as to whether change has occurred.
  56. Preventive nursing actions
    Promote health and prevent illness to avoid the need for acute or rehabilitative health care.
-Primary prevention aimed at health promotion and illness prevention.
-Secondary prevention focuses on people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions.
-Tertiary prevention involves minimizing the effects of long-term illness or disability, including rehabilitation measures.
  57. Adverse reaction
    Is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention?
  58. Counseling
    Direct care method that helps a patient use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships
  59. The focus of teaching is
    The intellectual growth or the acquisition of new knowledge or psychomotor skills
  60. Physical care techniques include
    Involve the safe and competent administration of nursing procedures. Common methods for administering physical care techniques appropriately include protecting you and the patient from injury, using safe patient handling techniques, using proper infection control practices, staying organized, and following applicable practice guidelines.
  61. Implementation skills
    Implementation skills includes cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities).
  62. Anticipating and preventing complications
    Risks to patients come from both the illness and the treatments
  63. Organizing resources and care delivery
    Organizing resources and care delivery involves organization of equipment, skilled personnel, and the environment. This makes timely, efficient, skilled patient care possible.
  64. Reviewing & Revising the existing nurse care plan
    If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan
  65. Reassessing the patient
    Reassessing the patient is a continuous process that occurs each time you interact with a patient; you collect new data, identify a new patient need, and modify the care plan
  66. What are the five preparatory activates for implementation of safe and effective nursing care.
    Reassessing the patient
. Reviewing & revising the existing nurse care plan
 Organizing resources and care delivery.
 Anticipating and preventing complications
. Implementation nursing interventions
  67. Nursing Interventions Classification (NIC) interventions
    Offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes
  68. Standing orders
    Is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for patients with identified clinical problems.
  69. Clinical practice guideline
    Set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations.
  70. Many patients have common health care problems; thus standardized interventions for these health problems make it quicker and easier for nurses to intervene.
    ->Nurse/Physician initiated standardized interventions- Clinical guidelines or protocols, Preprinted (standing) orders, and Nursing Interventions Classification (NIC) interventions.
->Professional level- The American Nurses Association (ANA) defines standards of professional nursing practice, which include standards for the implementation step of the nursing process.
  71. Gordons 11 functions of health patterns
    1)Health Perception 2) Nutritional 3) Elimination4) Activity 5) Sleep 6) Cognitive 7) Self- perception 8) Role-relationship patterns 9) Sexuality 10) Coping 11) Values
  72. Nursing intervention
    Is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes.
Ideally the interventions a nurse uses are evidenced based, providing the most current, up-to-date, and effective approaches for managing patient problems.
Interventions include direct and indirect care aimed at individuals, families, and/or the community.
  73. Seeking necessary knowledge about the steps of the procedure shows humility.
    The nurse recognizes that she needs clarification from a senior colleague. Another example of a critical thinking attitude is confidence. In this case confidently inserting an IV line allows the nurse to convey expertise and a sense of calm, leading the patient to trust the nurse. Following policy and procedure is an example of following standards of care, not of a critical thinking attitude. Making sure that the dressing is covered is a step in following good standards of IV care but is not a critical thinking attitude.
  74. When a nurse performs a new or unfamiliar procedure
    such as giving a new medication, it is important to assess personal competency and determine if new knowledge or assistance is needed. The nurse’s best action is to check with the pharmacist about the medication. Having another nurse check the dosage is appropriate if the nurse is still uncertain about the medication. Once the nurse feels prepared, the medication is administered as prescribed. You never ask a colleague to give a medication to a patient to whom you are assigned.
  75. Standing order
    A preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/ or diagnostic procedures for specific patients with identified clinical problems. It directs the conduct of patient care in a specific clinical setting.
  76. Preventive nursing actions
    Promotes health and prevents illness to avoid the need for acute or rehabilitative health care.
  77. Patient adherence
    patient and family invest time in caring out required treatment
  78. Nursing interventions
    performed any treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes.
  79. Lifesaving measures
    is a physical care technique that you use when a patient’s physiological or psychological state is threatened
  80. Interdisciplinary Care Plan
    plans that represent the contributions of a lot different disciplines caring for a patient.
  81. Instrumental activities of daily living (IADLs)
    include such skills as shopping, preparing meals, house cleaning writing checks and taking medications. Implemented when someone loses their ability independently live in society.
  82. Indirect care,
    interventions that are performed on behalf of a patient or group of patients, that are performed away from the patient. Examples are infection control and managing the patient’s environment.
  83. implementation
    the 4th step in the nursing process, begins after care plan has been developed.
  84. Direct care
    interventions or actions performed through interactions with the patient
  85. Counseling
    A direct care method that helps a patient use a problem- solving process to recognizing and managing and facilitate interpersonal relationships.
  86. Clinical practice guideline
    or protocol is a systematically developed set of statements that help nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations.
  87. Adverse reaction
    is a harmful or unintentional effect of a medication, diagnostic test, or therapeutic intervention. Advanced reactions can possibly follow and y nursing intervention; thus learning to anticipate and know which advanced reactions to expect is important
  88. Activities of Daily living (ADLs);
    are activities usually performed in the course of a normal day, including ambulation, eating, dressing, bathing and grooming. Patients need for help with ADS can be permeate, temporary or rehabilitees.
  89. To complete any nursing procedure
    you need to know the procedure, its frequency, the steps, and the expected outcomes.
  90. When you delegate aspects of a patient’s care
    you are responsible for ensuring that each task is assigned appropriately and completed according to the standard of care.
  91. Methods used to ensure that you administer physical care techniques appropriately include
    protecting you and the patient from injury, using proper infection control practices, staying organized, and following applicable practice guidelines.
  92. To anticipate and prevent complications
    identify risks to the patient, adapt interventions to the situation, evaluate the relative benefit of a treatment versus the risk, and initiate risk-prevention measures.
  93. Use good judgment and sound clinical decision making when
    performing any intervention to ensure that no nursing action is automatic.
  94. Before beginning to perform interventions
    make sure that the patient is as physically and psychologically comfortable as possible.
  95. The implementation of nursing care often requires
    additional knowledge, nursing skills, and personnel resources.
  96. When preparing to perform an intervention
    reassess the patient, review and revise the existing nursing care plan, organize resources and care delivery approaches, anticipate and prevent complications, and implement the intervention.
  97. Clinical guidelines or protocols are evidence-based documents
    that guide decisions and interventions for specific health care problems.
  98. Always think first and determine if an intervention
    is correct and appropriate and if you have the resources needed to implement it.
  99. A direct-care intervention
    is a treatment performed through interactions with a patient that can include nurse-initiated, physician-initiated, and collaborative approaches.
  100. Implementation is the fourth step of the nursing process
    which nurses initiate interventions that are designed to achieve the goals and expected outcomes of the patient’s plan of care.
  101. The Nursing Interventions Classification (NIC) taxonomy
    Provides a standardization to assist nurses in selecting suitable interventions for clients' problems
  102. List six responsibilities of the nurse when seeking consultation
    1.Identify the general problem area 
2. Direct the consultation to the right professional 
3. Provide the consultant with relevant information about the problem area 
4. Do not prejudice or influence the consultants 
5. Be available to discuss the findings and recommendations 
6. Incorporate the recommendations into the plan of care
  103. Consultation
    Is a process in which you seek the expertise of a specialist to identify ways to handle problems in client management or the planning and implementation of therapies
  104. Concept maps
    A concept map provides a visually graphic way to show the relationship between patient's nursing diagnoses and interventions.
- When planning care for each nursing diagnosis, analyze the relationships among the diagnoses. Draw dotted lines between nursing diagnoses to indicate their relationship to one another
  105. Describe Critical Pathways
    Patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time); their main purpose is to deliver timely care at each phase of the care process for a specific type of patient.
Clearly defines transition points in patient progress and draws a coordinated map of activities by which the health. care team can help to make these transitions as efficient as possible.
Improve continuity of care because they clearly define the responsibility of each health care discipline.
  106. What are the components of a well written nursing intervention
    Actions, Frequency, Quantity, Method, or person to perform them.
  107. How do SWCP differ from care plans used in hospitals?
    - A student care plan helps you apply knowledge gained from the nursing and medical literature and the classroom to a practice situation.
-Students typically write a plan of care for each nursing diagnosis.
-The student care plan is more elaborate than a care plan used in a hospital or community agency because its purpose is to teach the process of planning care.
  108. Student written care plan
    Student written care plan (SWCP)
Useful for learning the problem-solving technique, nursing process, skills of written communication, and organizational skills needed for nursing care.
  109. Describe a Student care plan
  110. Interdisciplinary care plans
    Include contributions from all disciplines involved in patient care.
Designed to improve the coordination of all patient therapies and communication among all disciplines.
  111. Define the purpose of the nursing care plan
    The nursing care plan should direct clinical nursing care and decrease the risk of incomplete, incorrect, or inaccurate care
Identifies and coordinates resources for delivering care
Lists the interventions needed to achieve the goals of care
  112. Nursing care plan
    Includes nursing diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluation findings
  113. The six factors that nurses use to select nursing interventions for a specific patient.
    1. Characteristics of the nursing diagnosis 
2. Goals and expected outcomes 
3. Evidence-based interventions 
4. Feasibility of the interventions 
5. Acceptability to the patient 
6. Your own competency
  114. -Collaborative intervention
    Requires the combined knowledge, skill, and expertise of multiple health care professionals
  115. -Dependent nursing intervention
    Physician-initiated intervention 
Requires an order for a physician or other health care professional
  116. Types of Interventions
    Independent nursing interventions- Nurse-initiated intervention
Dependent nursing interventions- Physician-initiated interventions
Collaborative interventions- Interdependent interventions -Independent nursing intervention; Nurse initiates;
Does not require direction or an order from another health care professional
  117. Nursing Interventions
    Treatments or actions based on clinical judgment and knowledge that nurses perform to meet patient outcomes.
--Choosing suitable nursing interventions involves critical thinking and your ability to be competent in 3 areas:
 1. Knowing the scientific rationale for the intervention
 2. Possessing the necessary psychomotor and interpersonal skills
 3. Being able to function within a particular setting to use the available health care resources effectively.
  118. Critical Thinking in planning nursing care
    Nursing interventions, 
Independent, 
Dependent, 
Collaborative nursing interventions

The 6 factors nurses use to select nursing diagnoses.
  119. Seven guidelines to follow when writing goals and expected outcomes
    Patient-centered goalOutcomes and goals reflect the patient behavior and responses expected as a result of nursing interventions  Singular goals/outcomesAddresses only one behavior or response per goal  ObservableThe nurse should be able to observe if a change takes place in a patient's status.  MeasurableTerms describing quality, quantity, frequency, length, or weight allow the nurse to evaluate outcomes precisely.  Time-limitedWritten so it indicates when the nurse expects the response to occur.  MutualThe patient and nurses agree on the direction and time limits of care.  RealisticPatient is able to achieve
  120. Nursing-sensitive patient outcome
    An individual, family, or community state, behavior, or perception that is measurable in response to a nursing intervention
  121. The time frame for goals depends on
    The nature of the problem, etiology, overall condition of the client, and treatment setting
  122. Long-term goal
    Objective behavior or response that you expect a patient to achieve over a long period, usually over several days, weeks, or months.
  123. Short-term goal
    Objective behavior that you expect the client wilt achieve in a short time, usually less than one week.
  124. Patient-centered goal
    Specific and measurable behavior or response that reflects a patient's highest possible level of wellness and independence in function.
  125. Expected outcome
    A measurable criterion to evaluate goal achievement.
  126. Goal
    Desired change in a patient's condition or behavior. Time-limited
  127. Goals and Expected outcomes are:
    Specific statements of patient behavior or physiological responses that you set to resolve a nursing diagnosis or collaborative problem.
During planning you select goals and outcomes for each nursing diagnosis to provide a clear focus for the type of interventions needed to care for your patient and then to evaluate the effectiveness of these interventions.
The goals and outcomes need to meet established intellectual standards by being relevant to patient needs, specific, singular, observable, measurable, and time limited.
  128. Maslow's Hierarchy of Needs (High-to lowest priority)
    Listed Most Important - Least important but can change depending on the circumstance.
Physiological: Basic Human Needs< Oxygen-Fluids-Nutrition-Body Temperature-Elimination-Shelter-Sex
Safety and Security: Physical and Psychological safety
Love and belonging needs
Self-esteem
Self-actualization
  129. Nurse established "Low" priority...
    Are not always directly related to a specific illness or prognosis but affect the patient's future well-being.
  130. Nurse established "Intermediate" priority...
    Involve no emergent, non-threatening needs of patients.
Ex: deficient knowledge, impaired physical mobility
  131. Nurse established "high" priority...
    If untreated, result in harm to a patient or others (those related to airway status, circulation, safety, and pain)
  132. Priority setting
    The ordering of nursing diagnoses or patient problems using determinations of urgency and/or importance to establish a preferential order for nursing actions.
  133. Planning involves:
    Setting priorities, 
Identifying patient-centered goals and expected outcomes, 
and Select interventions for the nursing care plan.
  134. When making a consultation
    first identify the general problem, direct the consultation to the right professional, and provide the consultant with relevant information about the problem.
  135. Consultation increases your knowledge about
    a patient’s problem and helps in learning skills and obtaining the resources needed to solve the problem.
  136. Correctly written nursing interventions include
    actions, frequency, quantity, method, and the person to perform them.
  137. The NIC taxonomy provides
    a standardization to help nurses select suitable interventions for patients’ problems.
  138. A concept map provides
    a visually graphic way to show the relationship between patients’ nursing diagnoses and interventions.
  139. Care plans and critical pathways
    increase communication among nurses and facilitate the continuity of care from one nurse to another and from one health care setting to another.
  140. During a nursing handoff
    nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions.
  141. Physician-initiated interventions
    require specific nursing responsibilities and technical nursing knowledge.
  142. Nurse-initiated interventions
    require no order and no supervision or direction from others.
  143. An expected outcome is an objective criterion
    for goal achievement.
  144. A patient-centered goal is
    singular, observable, measurable, time limited, mutual, and realistic.
  145. In setting goals the time frame depends
    on the nature of the problem, etiology, overall condition of the patient, and treatment setting.
  146. Goals and expected outcomes provide
    clear direction for the selection and use of nursing interventions and the evaluation of the effectiveness of the interventions.
  147. Priorities help you
    anticipate and sequence nursing interventions when a patient has multiple nursing diagnoses and collaborative problems.
  148. During planning determine
    patient goals, set priorities, develop expected outcomes of nursing care, and select interventions for the nursing care plan.
  149. A community-based health care setting such as home health
    must work with patients and their families to set goals and outcomes that ultimately lead to a plan that allows them to provide the majority of care themselves.
  150. The skin remaining intact is an appropriate goal
    for the patient’s at-risk diagnosis.
  151. The priority is to reconnect the drainage tube
    This can be done quickly and prevents fluid loss and reduces risk of infection spreading up into the tube. Next the nurse turns the patient for comfort. With 100 mL of fluid remaining, the nurse has time to perform these tasks. The nurse can inspect the IV dressing last, after going to obtain the next IV fluid bag.
  152. Pain control is a priority
    because it is severe and affects the patient’s ability to rest after surgery and be able to perform necessary activities. A change in vital signs is a priority, and the change could be related to the patient’s pain. However, because of the nature of surgery, the nurse has to reassess for any bleeding, which lowers blood pressure. Attending to the family is important to lend the patient needed support, but it is not the initial priority. Finally the nurse must attend to urgent patient needs before completing a report.
  153. The goal is incorrect.
    It is written as an intervention, and there is no time frame. The goal should be written as “Patient is able to ambulate independently within 72 hours.” The outcomes are not singular, and it is more appropriate to time them separately. To improve the outcomes, Tonya writes, “Patient will report pain below level of 4 during movement within 24 hours,” and, “Patient will not splint incision when moving within 48 hours.” In this example Tonya places a priority on administering analgesia to lessen pain severity and uses other interventions to ultimately reduce the patient’s need to splint the incision during walking.
  154. Selection of interventions, consider:
    Characteristic of the nursing diagnosis. Goals and expected outcomes. Evidence based, research or proven practice guidelines fro interventions. Feasibility of intervention. Acceptability to the patient
  155. Nursing interventions involves critical thinking and the ability to be competent in three areas:
    Knowing the scientific rational for interventions. Possessing the necessary psychomotor and interpersonal skills. Being able to function within a particular setting to use the available healthcare resources effectively.
  156. Short term goal
    an objective behavior that you expect a patient to achieve in a short time usually less than a week.
  157. Scientific rational
    the reason you choose a specific nursing action based on supporting evidence.
  158. Priority setting
    the order of nursing diagnosis or patient problems using determination of urgency and or importance to establish a order for nursing actions. Ranking patients and problems in order of need.
  159. Planning
    involves setting priorities identifying patient centered goals and expected outcomes, and prescribing individualized nursing interventions.
  160. Patent centered goal;
    reflect a patients highest possible level of wellness and independence in function. It is realistic and based on patient’s needs and rescores.
  161. Nursing sensitive patent outcome
    is a measureable patient, family or community state, behavior, or perception largely influenced by and sensitive to nursing interventions.
  162. Nursing care plan
    includes nursing diagnosis, goals and expected outcomes, specific nursing interventions, and a section for evaluation finding so any nurse is able to quickly identify a patents clinical needs and situations.
  163. Long- term goal
    is an objective behavior or response that you expect a patient to achieve over a long period of time, usually several days, weeks or months.
  164. Interdisciplinary care plan
    include contributions from all disciplines involved in patient care.
  165. Independent nursing interventions
    nurse initiated interventions
  166. Goal;
    is a broad statement that describes a change in a patient’s condition or behavior.
  167. Expected outcomes
    is a measurable criterion to evaluate goal achievement. Once an outcome is met you then know that a goal has been at least partially achieved.
  168. Dependant nursing interventions
    physician initiated interventions
  169. Critical pathway
    are patient care management plans that provide the multidisciplinary health care team with the activates and tasks to be put into practice sequentially over time; their main purpose is to deliver timely care at each phase of the care process for a specific type of patient.
  170. Consultation;
    a process by which you seek the expertise of a specialist such as your nursing instructor, a clinical nurse educator to identify ways to handle problems in patient management or the planning and implication of therapies.
  171. Collaborative interventions
    or interdependent collaborations are therapies that require the combined knowledge, skill and experience multiple healthcare professionals.
  172. errors in the diagnostic statement
    • Reduce errors by selecting appropriate, concise, and precise language using NANDA-I terminology. Be sure that the etiology portion of the diagnostic statement is within the scope of nursing to diagnose and treat.
1- identify the patient's response
    • 
2-identify the NANDA-I diagnostic statement
3-identify a treatable etiology of risk factors
4- identify the problem caused by the treatment or diagnostic study

    • 5- identify the patient response to equipment

    • 6-identify the patient's problem rather than your problems with care
    • 
7-identify the patient problem rather than the nursing intervention

    • 8-identify the patient problem rather than the goal of care

    • 9-make professional rather than prejudicial judgments

    • 10-avoid legally inadvisable statements

    • 11-identify the problem and etiology to avoid a circular statement

    • 12-identify only one patient problem in a diagnostic statement
  173. care plan
    map for nursing care and demonstrates your accountability for patient care.
  174. PES
    • P (problem)—NANDA-I label—Example: impaired physical mobility
• E (etiology or related factor)—Example: incisional pain
• S (symptoms or defining characteristics)—briefly lists defining characteristic(s) that show evidence of the health problem. Example: evidenced by restricted turning and positioning 
PES diagnostic statement: Impaired physical mobility related to
  175. health promotion nursing diagnosis
    clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise
  176. risk factors
    the diagnostic-related factors that help in planning preventive health care measures
  177. risk nursing diagnosis
    Describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community.
  178. Critical thinking
    necessary in identifying nursing diagnoses and collaborative problems so you appropriately individualize care for your patients.
  179. related factor
    a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis.
associated with a patient's actual or potential response to the health problem and can change by using specific nursing interventions
  180. clinical criterion
    an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a diagnostic conclusion
  181. defining characteristics
    patterns of data clusters. the clinical criteria that are observable and . each NANDA-I approved nursing diagnosis has an identified set of defining characteristics that support identification of a nursing diagnosis
  182. data cluster
    set of signs or symptoms gathered during assessment that you group together in a logical way
  183. decision-making steps
    data clustering, identifying patient health problems, and formulating the diagnosis
  184. diagnostic reasoning process
    involves using the assessment data you gather about a patient to logically explain a clinical judgment, in this case a nursing diagnosis
  185. use of standard formal nursing diagnostic statements purpose
    • Provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding the patient's needs

    • • Allows nurses to communicate (e.g., written and electronic) what they do among themselves with other health care professionals and the public

    • • Distinguishes the nurse's role from that of the physician or other health care provider
    • 
• Helps nurses focus on the scope of nursing practice

    • • Fosters the development of nursing knowledge

    • • Promotes creation of practice guidelines that reflect the essence of nursing
  186. application of nursing practice
    • Develop a familiarity with agency documentation systems and the use of nursing diagnosis.

    • • Use of nursing diagnosis offers an approach to ensure more comprehensive nursing assessment.
    • 
• Use of nursing diagnosis can improve selection of nursing interventions by all nurses in a practice setting.
  187. collaborative problem
    an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient's status. Nurses manage collaborative problems such as hemorrhage, infection, and paralysis using medical, nursing, and allied health (e.g., physical therapy) interventions 
occur or probably will occur in association with a specific disease, trauma, or treatment
  188. Nursing diagnosis
    second step of the nursing process (Fig. 17-1), classifies health problems within the domain of nursing. A nursing diagnosis such as acute pain or nausea is a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat (NANDA International, 2012)
  189. Risk nursing diagnosis
    factors that the individual, family or community are at risk of developing. These diagnosis do not have related factors or defining characteristics because they have not occurred yet.
  190. Nursing Diagnosis
    Formal statement of an actual or potential health problem that nurses can legally and independently treat: the second step in the nursing process, during which patients actual and potential unhealthy responses to an illness or condition are identified.
  191. NANDA international (NANDA-I);
    North American Nursing Diagnostic Association – International
  192. Medical diagnosis
    classifies health problem with in the domain of nursing. A clinical judgment about an individual, family or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.
  193. Health promotion nursing diagnosis
    reflects the readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise
  194. Etiology
    the study of all the factors that may be involved in the development of a disease.
  195. Diagnostic label
    the name of the nursing diagnosis as approved by NANDA-I
  196. Defining characteristics
    the clinical criterion that are observable and verifiable
  197. Data cluster
    a set of signs and symptoms gathered during an assessment that you group together in a logical way
  198. Collaborative problem
    an actual of potential physiological complication that nurse monitor to detect the onset of changes in the patient status.
  199. Clinical criterion;
    is an objective or subjective sign, symptom or risk factor that when analyzed with other criteria, leads to a diagnostic conclusion
  200. Actual nursing diagnosis
    describes human responses to health conditions or life processes that exist in an individual, family, or community.
  201. Nursing diagnostic errors occur
    by errors in data collection, interpretation and analysis of data, clustering of data, or the diagnostic statement.
  202. A concept map is a visual representation
    of a patient’s nursing diagnoses and their relationship with one another.
  203. Risk factors serve as cues to indicate that
    a risk nursing diagnosis applies to a patient’s condition.
  204. The “related to” factor of the diagnostic statement
    helps you to individualize a patient’s nursing diagnoses and provides direction for your selection of appropriate interventions.
  205. A three-part nursing diagnosis
    using a PES format, includes a diagnostic label, etiological statement, and symptoms or defining characteristics.
  206. A nursing diagnosis
    is usually written in a two-part format, including a diagnostic label and an etiological or related factor.
  207. Absence of defining characteristics
    suggests that you reject a proposed diagnosis.
  208. When an assessment reveals defining characteristics that apply to more than one nursing diagnosis,
    gather more information to clarify your interpretation.
  209. Defining characteristics
    are subjective and objective clinical criteria that form clusters, leading to a diagnostic conclusion.
  210. The nursing diagnostic process
    includes data clustering, identifying patient needs or problems, and formulating the nursing diagnosis or collaborative problem.
  211. One purpose of nursing diagnosis
    is that it provides a precise definition of a patient’s problem that gives nurses and other members of the health care team a common language for understanding the patient’s needs.
  212. Accurate diagnosis of patient problems
    ensures the selection of more effective and efficient nursing interventions.
  213. The nursing diagnostic process
    is unique from that of medical diagnosis in that patients become involved in the diagnostic process when possible
  214. The diagnostic process
    a clinical judgment that involves reviewing assessment information, recognizing cues and patterns in the data, and identifying the patient’s specific health care problems.
  215. Diagnostic conclusions
    include problems treated primarily by nurses (nursing diagnoses) and those requiring treatment by several disciplines (collaborative problems)
  216. Common practices related to Documentation
    Documentation should be timely, thorough, and accurate. 
Record all observations.
Pay attention to facts and be descriptive.
Record objective information in correct, accurate terminology.
Do not generalize or form judgements.
  217. Interpreting Assessment Data:
    You determine the presence of abnormal findings.
Recognize that further observations are needed to clarify information.
Begin to identify the patient's health problems.
The patterns of data reveal meaningful and usable clusters.
Data cluster- A set of signs or symptoms that you group together in a logical way.
  218. Patient Expectations
    Patient's understanding of why he or she is seeking health care. The assessment of patient expectations is not the same as the reason for seeking medical care, although they are often related. Failure to identify a patient's expectations of health care providers results in poor patient satisfaction
  219. Chief Concern
    Reason for Seeking Health Care
  220. Sources of Data:
    Patient- (Best Source) when conscious, alert, and able to answer questions.
Family & Significant others- (Primary sources of information for infants or children; critically ill adults; and the mentally handicapped, disoriented, or unconscious)
Health Care Team-
Medical Records- Medical history, laboratory, diagnostic test results, current physical findings, and the primary health care provider's treatment plan.
Other records and Scientific Literature- Educational, military, and employment records
  221. Types of Data:
    Subjective data- Patients' verbal descriptions of their health problems. Includes feelings, perceptions, and self-report of symptoms.
Once a patient provides subjective data, explore findings further by collecting objective data.
Objective data- Observations or measurements of a patient's health status. Be clear, precise and consistent.
  222. Example of problem-focused patient assessment: Pain
    Nature of Pain - Describe your pain for me. Place your hand over the area that hurts or is uncomfortable. Observe nonverbal cues, observe where patient points to pain; note if it radiates or is localized
2. Precipitating factors - Do you notice if pain worsens during any activities or specific time of day? Is pain associated with movement? Observe if patient demonstrates nonverbal signs of pain during movement, positioning, swallowing
3. Severity - rate your pain on a scale from 0 to 10. Inspect area of discomfort, palpate for tenderness.
  223. Value-belief pattern
    Describes patterns of values, beliefs including spiritual practices, and goals that guide patient's choices or decisions
  224. Coping-stress tolerance pattern
    Describes patient's ability to manage stress; sources of support; effectiveness of the patterns in terms of stress tolerance
  225. Sexuality-reproductive pattern
    Describes patient's patterns of satisfaction and dissatisfaction with sexuality pattern; patient's reproductive patterns; premenopausal and postmenopausal problems
  226. Role-relationship pattern
    Describes patient's patterns of role engagements and relationships
  227. Self-perception-self-concept pattern
    Describes patient's self-concept pattern and perceptions of self. Example: self-concept/worth, emotional patterns, body image
  228. Cognitive-perceptual pattern
    Describes sensory-perceptual patterns; language adequacy, memory, decision-making ability
  229. Sleep-rest pattern
    Describes patterns of sleep, rest, and relaxation
  230. Activity-exercise pattern
    Describes patterns of exercise, activity, leisure, and recreation; ability to perform activities of daily living
  231. Elimination pattern
    Describes pattern of excretory function. Example: bowel, bladder, and skin
  232. Nutritional-metabolic pattern
    Describes patient's daily/weekly pattern of food and fluid intake. Example: food preferences or restrictions, special diet, appetite; actual weight, weight loss or gain
  233. Health perception-health management pattern
    Describes patient's self-report of health and well-being; how patient manages health. Example: frequency of health care provider visits, adherence to therapies at home; knowledge of preventative health practices
  234. Functional health patterns
    An example of a structured database format, one approach to perform a comprehensive assessment. Gordon's functional health patterns model offers a holistic framework for assessment of any health problem. The health patterns are listed below.
  235. Observational overview using cues and forming inferences.
    Male patient in bed, looks uncomfortable. Patient presents with discomfort in surgical area. 
Cues
- Lies still with arms along sides; tense
- States has not turned for some time
- Reports pain a 7 on a scale of 0 to 10
Inferences
- Pain is severe
- Pain limits patient's ability to move and reposition self
  236. A concomitant symptom
    symptom that occurs along with a primary symptom. The finding is subjective based on patient self-report. There is no clinical inference since the nurse is not trying to find the meaning of the findings. The patient is reporting nausea, but there is no validation or confirmation with another source.
  237. A probing question encourages
    a full description without trying to control the direction of the patient’s story. It requires further open-ended statements
  238. These form a pattern of a problem with wound healing
    the nurse collects two assessment findings.  the nurse is asking an open-ended question about the patient’s
  239. Active listening allows
    the patient to speak and shows the nurse’s respect for what he or she has to say. Back channeling reinforces interest in what the patient has to say and shows the nurse’s desire to hear the full story. Using open-ended questions encourages the patient to tell his or her story and actively describe his or her health status. Validation simply confirms accuracy of data collected. Closed-ended questions do not encourage storytelling.
  240. The nurse is focusing on the patient’s nutritional status
    asking specific questions to assess his diet history.
  241. SNOMED CT® (Systematized Nomenclature of Medicine Clinical Terms®)
    Clinical terminology standards that influence how we document clinical practice and access health data.
  242. Personal Information Protection and Electronic Documents Act (PIPEDA)
    Identify specific limitations to the disclosure of personal information—whether in electronic or other forms. Regardless of the practice setting or mode, you are professionally, ethically, and legally obligated to protect all personal information of patients in your care
  243. Nursing Informatics
    A specialty area of nursing practice dedicated to optimal use of technology to support professional practice and enable optimal patient outcomes, has responded to this challenge and continues to support the progression of the effective use of information in nursing practice and documentation.
  244. International Medical Informatics Association (IMIA)
    A variety of international informatics organizations that host special-interest groups in NI
  245. International Classification for Nursing Practice® (ICNP®)
    For standardization of nursing data for comparability and analysis, as well as evidence-based practice. The use of a single unified terminology to represent nursing practice.
  246. Electronic Health Record (EHR)
    A longitudinal record of an individual's health status (including diagnosed morbid conditions), diagnostic tests, treatments, and results—that will be interoperable with a pan-Canadian EHR
  247. Canada Health Infoway
    Has a national mandate to generate consensus on health information standards, to drive the national agenda of creating an EHR system, and to act as the liaison to international standards development organizations
  248. C-HOBIC (Canadian Health Outcomes for Better Information and Care)
    This organization is implementing a standardized nursing documentation approach for capturing, analyzing, and reporting nursing-sensitive outcomes for acute care, complex continuing care, long-term care, and home care.
  249. In Gordens 11 functional health patterns what are health perceptions
    Health Management patterns

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Author:
RobinMaupin
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318783
Filename:
Fundamentals of nursing/ Nursing Roles
Updated:
2016-04-11 20:33:30
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Fundamentals nursing Nursing Roles
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Fundamentals of nursing/ Nursing Roles
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