Unit 6-The nursing process

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Unit 6-The nursing process
2010-10-09 22:56:21

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  1. The nursing process
    A series of planned steps and actions directed toward meeting the needs and solving the problem of the clients and thier families
  2. Characteristics of the nursing process
    • Systemic
    • oraganize
    • cyclic
    • dynamic
    • goal oriented
    • interpersonal
  3. critical thinking/cognitive/intellectual
    • Purposeful, goal directed thinking that aims to make judgements based on facts.
    • Requires a commitiment to seek the best way based on the most current research and practical findings.
    • Involves processing information from more than one source to make a decision.
  4. Critical thinking includes
    • Reflection
    • Language
    • Intuition
    • Inductive reasoning
    • Deductive reasoning
  5. Inductive reasoning
    Use specific data (signs and Symptoms) to identify a general data (dx)
  6. Deductive reasoning
    Use general data (dx) to identify a specific data (signs and sx)
  7. Four types of skills needed in the nursing process
    • Critical thinking/cognitive/Intellectual
    • Communication/Interpersonal
    • Technical/Psychomotor
    • Emotional intelligence
  8. Emotional intelligence
    • the ability to accurately perseive, express, understand, and manage both one's own emotions and the emotions of others.
    • the ability to manage emotions and handle stress are important predictors of career succes.
  9. components of the NP
    • Assessing
    • Diagnosing
    • Planning
    • Implementing
    • Evaluating
  10. Framework for accountability for all
    • Cl- improves quality of care
    • Nurse- Knows that professional standards of care are being met, legally and ethically sound.
    • Both- Time & resourses are used efficiently for the benefit of both nurse and cl.
  11. Assesment
    • the systematic and continuous collection, validation, and communication of the client
    • remaining steps depend on complete, accurate, factual, and relevent data
  12. purpose of assessment
    to form a database and obtain a baseline
  13. types of data
    • Objective-What you can observe, you can see, touch, hear, smell and taste.
    • Subjective- stated data. Based o opinion and can not be varified
    • Constant- data that does not change
    • Variable- data that changes
  14. Sources of data
    • Primary- from the client, verbal and nonverbal
    • Secondary- from others, family, nurses, records
    • Tertiary- from text books, articles, reseach
  15. Methods of collecting data
    • Observing
    • Interviewing
    • Examining
  16. Health history
    an organized series of questions for obtaning specific information about the cl.
  17. Health history includes
    • Basic Needs
    • Life span
    • Cultural diversity
  18. Physical assesment
    • Inspection
    • Palpation
    • Percussion
    • Auscultation
  19. Nursing diagnosis
    Acutal or potential health problem that can be prevented or resolved by independant nursing intevention
  20. summary of nursing assesment
    • collect data
    • validate/verify data
    • organize data
    • identify patterns
    • report and record data
  21. Planning
    • designing a plan of care for the client that will result in solving or preventing client health problems
    • Must include (who will do what by when)
  22. weasel words
    know, learn, understand, feel, want
  23. Action verbs
  24. Components of planning
    • Setting priorities
    • Establishing cl goals and outcome goals
    • Planning nursing strategies/implmentations/orders/interventions
  25. concept map
    • diagram of your conceptualization of nursing care to show connections and interrelationships.
    • Mind mapping
  26. 5 main reason for writing a nursing care plan
    • 1. Individualized care
    • 2. Continuity of care
    • 3. Direction about what needs to be documented
    • 4. Guide for assigning staff and tasks
    • 5. Documentation for third party reimbursement
    • 6. Provides written proof for accountibility
  27. Discharge planning
    consider availibility of clients needs, teaching needs, home environment
  28. Implementation
    where the care plan and medical/ collaborative orders are carried out
  29. Types of nursing actions
    • Independant
    • Dependent
    • Colllaborative/Interdependent
  30. Independent
    nurse is licensed to initiate these actions based on thier knowledge, education, and skills
  31. Dependent
    Nurse carries out physicians's orders
  32. Collaborative/ interdependent
    performed jointly by nurse and other members of the health care team
  33. Protocols
    written procedures to be followed in a partucular situation, may include both medical and nursing orders
  34. standing orders
    allows the nurse to initiate actions that ordinarily require the ordor or supervision of an MD
  35. Impelmenting strategies
    • A. Reassessing trhe cl
    • B. Determining the need for nursing care
    • C. Implementing nursing strategies= carring out the plan
    • D. Communicating the nursing orders, written and verbally
  36. Evaluation
    is the paln working? Measure and modify prn
  37. Evidence based practice
    a problem solving approch to practice that involves the conscientious use of the current best evidence in making decisions about cl care while also considering their values and preferences.