Nursing Process

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Nursing Process
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2010-01-04 01:13:32
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Nursing Process
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Nursing Process Ch. 5
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  1. Definition of nursing
    Is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through thte diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
  2. Define Nursing Process
    Serves as organizational framework for the practice of nursing. Is a systemic method by which nurses plan and provide care for patients.
  3. The six phases of the Nursing Process
    • Assessment
    • Diagnosis
    • Outcome Identification
    • Planning
    • Implementation
    • Evaluation
  4. Define Assessment
    Process by which a nurse through interaction with the client, significant others, and health care providers collects and analyzes data about the client.
  5. * The remamining phases of the nursing process depend on the accuracy and completeness of the initial data collection.
  6. Define Complete Assessment
    Involves a review and physical examination of all the body systems. Also includes cognitive, psychosocial, emotional, cultural, and spiritual. APpropriate for a patient who is stable and not in acute distress.
  7. Focus Assessment
    Advisable when patient is critically ill, disoriented, or unable to respond. Gathers information about a specific health problem. Are also performed continuosly throughout nurse-patient contact. Assessments made to determine progress toward the achievement of desired outcomes are also focus assessments.
  8. Cue
    Is a synonym for the subjective and objective data.
  9. Subjective data
    The verbal statements provided by the patient. Other terms for subjective data are symptoms and subjective cues.
  10. Objective Data
    Are observable and measurable signs. Can be recorded. Ex: Camera can record a rash, a sin lesion, or puffy eyes. A thermometer records temperature. Other terms for objective data are signs and objective cues.
  11. Sources of Data
    Data can be obtained from primary or secondary sources. Primary source is patient. Patient is considered to be most accurate reporter. Secondary sources include family members, significant others, medical records, diagnostic procedures, and nursing literature. Other health team professional are also secondary sources.
  12. Etiology
    Cause
  13. Methods of Data Collection
    Two basic methods are used to collect data. 1. Nurse conducts interview to obtain info about patient's health history. Nurse inquires about biographic data that provide info about the facts or events in a person's life. 2. Performance of a physical examination. Often guided by subjective data provided by the patient.
  14. Database
    A large store or bank of information
  15. Data Clustering
    Organizing the data collected. Related cues are grouped together. Attention is focused on health concern. ALso assists in the identification of nursing diagnosis.
  16. Diagnose
    Is to identify the type and cause of a health condition. The diagnosis provides the basis for determination of a plan of care to achieve expected outcomes.
  17. Problem
    Is any health care condition that requires diagnostic, therapeutic, or educational action.
  18. Guidelines that help the nurse identify the cues that have significance for nursing care.
    • Deviations from population norms
    • Change in patient's usual health status
    • Developmental delays
    • Dysfunctional behavior
    • Changes in usual behavior
  19. Nursing Diagnosis
    A clinical judgement about individual, family, or community responses to actual or potential health problems/life processes. Provides basis for selection of nursing interventions to acieve outcomes for which nurse is accountable. If nurse can't prescribe primary treatment, the problem is not a nursing diagnosis.
  20. Four components addressed when submitting a nursing diagnosis
    • Nursing Diagnosis title/label
    • Definition of the title/label
    • Contributing/ etiologic/ related factors
    • Defining characteristics
  21. Nursing Diagnosis Title/Label
    The name given to the problem is calle dnursing diagnosis. Provides concise name for the identified health problem. Place adjective in from of the noun. For example, Impaired Physical Mobility
  22. * NANDA, International recently changed the organization structure for the diagnostic labels. It is called Taxonomy II. Monitor language changes every two years.
  23. Definition
    Presents a clear, precise description of the problem. Helps identify the difference between similar nursing diagnoses.
  24. Contributing/ etiologic/ related factors & Risk Factors
    Contributing/ etiologic/ related factors are conditions that may be involved in the debelopment of a problem. These factors may become focus of nursing interventions. Contributuing factors are referred to "related to's". Risk Factors are those circumstances that increase susceptability of a patient to a problem. Also written as the "related to" in risk nursing diagnoses.
  25. Defining Characteristics
    Are Cues that tell how the diagnosis is manifested. The clinical cues, signs, and symptoms that furnish evidence that the problem exists. Cues, signs, and symptoms are written as "manifested by" in nursing diagnosis.
  26. Four types of diagnoses
    • Actual
    • Risk
    • Syndrome
    • Wellness
  27. Actual Nursing Diagnosis
    • Human responses to health condition / life processes that exist in an individual, family, or community. Supported by defining characteristics or related cues or inferences. Represented by a 3 part statement. 1. nursing Diagnosis label /title from NANDA list 2.
    • Contributing/etiologic/related factor 3. specific cues, signs, and symptoms. Connecting phrases join 3 parts. "Related to" links first & second. "Manifested by" joins second & third.
  28. Risk Nursing Diagnosis
    Human responses to health condition / life processes that may develop a vulnerable individual, family, or community. Supported by risk factors that contribute to increased vulnerability. Written as 2 part statements; 1. nursing Diagnosis label /title from NANDA list 2. the risk factors. Connected by the words "related to".
  29. Syndrome Nursing Diagnosis
    Used when a cluster of actual or risk nursing diagnosis are predicted to be present in certain circumstances. Written as a one part statement because diagnoses are so specific. Ex: Rape-trauma syndrome
  30. Wellness Nursing Diagnosis
    HUman responses to levels of wellness in a n individual, family, or community that have a readiness for enhancement. Written as a one part statement. The words "Readiness for enhanced" are used.
  31. Collaborative Problems
    Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage these problems by using physician-prescribed or nursing-prescribed interventions to minimize the complications of the events.
  32. Medical Diagnosis
    The identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures. Physician is licensed to make medical diagnosis. Ex: Diabetes mellitus, hepatitis B, Pneumonia. Diagnosis does not change.
  33. Differentiating Medical and Nursing Diagnoses
    Nurse addresses the patient's concerns about the medical problem.
  34. Outcomes
    Nurse develops outcomes for the established nursing diagnosis. Indicates the degree of wellness desired, expected, or possible for patient to avhieve. May be referred to as a patient goal.
  35. Goal statement
    Is about the purpose to which an effort is directed. Use the term "Desired patient outcome"
  36. * The desired patient outcome states the behaviors that the patient will be able to perform rather than what the nurse will do. Serve two functions; 1. They guide the selection of nursing interventions. 2. the outcome statement establishes the measuring standard that is used to evaluate the effectiveness of the nursing interventions.
  37. *the outcome statement should begin with the words "The patient will". Always use time frame.
  38. Planning
    During this phase the nurse establishes priorities of care, slects and converts nursing interventions into nursing orders, and communicates the plan of care using standardized languages or recognized terminology to document the plan. Nurse must decide what can be done to lessen or solve problem and avoid risk problems. Deciding on interventions to be taken are made during this phase.
  39. Priority Setting
    Prioritze nursing diagnoses by order of importance. A useful framework is Maslow's hierarchy of needs. Based on Principle that lower level needs must be met before higher level needs.
  40. * Time factors &severity of illness are important considerations when determining what problemsshould be addressed first. Priorities change as patient progresses through hospitalization.
  41. Nursing Interventions
    Are those activities that should promote the acievement of the desired patient outcome. Are classified as physician-prescribed interventions or nurse-prescribed interventions. Usually aimed at reducing or eliminating the causative factor.
  42. Physician-prescribed interventions
    ARe those actions ordered by a physician for a nurse or other health care professional to perform. Nursing judgement is still used.
  43. Nurse-Prescribed Interventions
    Are any actions that a nurse can legally order or begin independently.
  44. Writing Nursing Orders
    A detailed statement about the nursing intervention.

    • Should include;
    • Date
    • Signature of nurse responsible for care plan
    • SUbject
    • Action Verb
    • Qualifying Details
  45. Maslow's Hierarchy of Needs
    • Physiologic Needs (physical needs)
    • Safety & Security
    • Love & Belonging
    • Self-esteem
    • Self-actualization
  46. * The written nursing care plan is the product of the nursing process.
  47. Implementation Phase
    The established plan is put into action to promote outcome achievement. Includes ongoing activities of data collection, prioritization, performance of nursing interventions & documentation. Documentation is a vital component of implementation phase.
  48. Evaluation
    Is a determination made about the extent to which established outcomes have been achieved. Take several steps to complete evaluating phase; 1. Review the patient centred goals/desired patient outcomes establisehed earlier. 2. Nurse reassesses the patient to gather data in dicating actual response to nursing interventions. 3. Compare the actual outcome with the desired outcome and make critical judgement about whether outcome was achieved. Nurse makes one of three judgements or decisions; Outcome was achieved, not achieved, or partially achieved. Document! Plan of care is changed during this phase.
  49. Managed Care
    Is a health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame
  50. Case Management
    Now a certified nursing specialty, refers to the assignment of a health care provider to a patient so that the care of that patient is overseen by one individual. Advises nursing staff on specific nursing care issues, monitor's patient progress through to discharge, assists to receive required services, coordinates these services & evaluates the adequacy of these services.
  51. Clinical Pathways
    Are helpful additional components to case management. Is a multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high-risk, high-volume, high-cost cases.
  52. Variance
    Exit
  53. * When a patient does not achieve the projected outcome a variance has occured.
  54. Role of the LPN in the Nursing Process
    Assessing - Observe & Report significant cues to nurse or physician

    Diagnosisng - Assist with determination of accurate nursing diagnoses & gather further ifo to confirm or eliminate problem

    Expected Outcome / Planning - Assist with setting priorities, suggest interventions, assist with the development of goals

    Implementing - Assist with establishment of priorities, Carry out physician orders, Evaluate effectiveness

    Evaluating - Assist with the reevaluation of the patient health state after nursing interventions, suggest alternative nursing interventios when necessary.

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