Fundamentals Test 2
Card Set Information
Fundamentals Test 2
Method of anazlying a problem, determining alternatives, and selecting the appropriate action.
Diagnositc Reasoning Process
Skills used to make nuring diagnosis.
Functional Health Pattern
A framework for collecting and organzing nursing assessment data to ascertain the client's strengths and any actual or potentional dysfunctional patterns.
Organizing information to use cues to make acurate diagnosis.
Information that enters a system.
Systematic approach to providing nursing care using
**Problem solving method used in all settings with clients to ID and treat human responses to potential or actual health problems. This allows for individualized care.
The Nursing Process: Assessment
"Systematic gathering of info. related to the physical, mental, spiritual, socioeconoic and cultural status of an individual, group or community.
Nurses collect data about patients past, present or potential problems to develop complete database.
-Collect Data -- From primary and secondary sources.
-Organize Data -- Various ways include
: Head-to-Toe, Gordons and body systems
-Validate Data -- Check for accuracy and comparen normal vs. abnormal.
-Document Data -- Make sure you document accurately without your own "spin on things"
What do we determine in the Assessment?
Baseline info. on the client
Client's normal function
Client's risk for dysfunction.
Determine presensce of absence of dysfuncion.
Provide data for the diagnosi sphase.
Types of Assessments
Initial (admission) - Longer assessment that includes health history as well as current problems.
Focus - When we alread know what the patient's probelm is and we can focus on the probelm to see if it still exists or whether the status of the problem has changed.
Time-lapsed - Evaluate any changes in the client's functional health. Over a period of time could be weeks or months.
Emergency - Use this in ABCs, suicide and violence.
Observation - comprises more that the nurses's ability to "see" the client, nurses always use the senses
Vision, Smell, Hearing, and Touch. Also Intuition (little voice inside your head)
Subjective data - told
Objective data - measured
End-product of a system.
Systematic process that involves identifying and analyzing the problem, determining and weighing the possible solutions, choosing and implementing a solution, and evaluation the results.
Other that the client. Examples chart, family, ect.
Way of viewing the world or an organization in which the parts are seen in relation to the whole.
Process by which a system transforms, creates, and orgaizes input, resulting in a reorganization of the imput.
Who introduced the term "nursing process"
Lydia Hall in 1955.
Needs to be structured and puposeful. Interviewing helps obtain info. for the nursing history, consists of asking queustions to get subjective data from the client.
Phases of the Patient Interview
Prepatory Phase - research before nurse meets client.
Introductory Phase - (orientation) this is where you are able to establish a rapport, creat trust and relieve anxiety with small talk.
Maintence Phase - (working phase) nurse and client focus on specific goals. Ask open and closed ended questions.
Concluding Phase - (closing) Can be done by client or nurse. Review goals, maintain trust and make a plan.
Nursing Interview: Questioning
: Easily categorized info. with just yes or no answers. Just the facts!
: Allows client to control interview, nurse can clarify and summarize what patient is saying, good if you want more info.
Also open ended (usually more than a couple of words) and close ended questions.
What is a leading question?
When you tell your patient the answer you want to hear.
: You don't have any questions about your meds to you?
It should be
: Do you have any questions about your meds?
Conducting the Interview
Individualize your approach (each situation is different)
Active listening and pay attention to nonverbal communication such as body language.
Use mostly open-ended questions.
Use 10th grade level speech they can't understand. No "health jargon"
Curb you curiosity...only find out what you NEED to know not what you may want to know.
Do not give advice or voice approval/disapproval. Every patient has right to second opinion.
"Double-checking the info." process of confirming the accuracy of assessment data collected.
Compare data to normal function
: Example runners may have lower HR, but this is normal for them.
Checking consistency of cues
: Example clients statements may differ at different times in the interview.
Data are far outside normal range
: You can check journals, textbooks ect to see what the problem may be.
Factors may be present that interfere with accurate measurement.
Reflect on the Assessment
Make sure you have data that is complete, validated and accurate.
Record all findings.
If you needed to follow up on anything make sure you did.
Review the physical assessment, observation and examination.
Document the Data ASAP using the facts and clients own words. Record only pertinent data.
What is a Medical Diagnosis?
IDs a disease, illness or injury. Any pathological problems. Examples: Asthma, COPD Diabetes
What is a Nursing Diagnosis?
Nurse Driven. Invovles data anaylsis and identrification of problems, risks and strenghts could be actual or potential.
When clients are at risk for developing the same complications always a potential for it, and it takes both the nurse and the physician to care for it.
Components or Nursing Diagnosis
Diagnostic Label - Name of the nursing diagnosis
Descriptors - ex. ability, deficient, compromised, effecive ect.
Defining Characteristics - can be subjective or objective there may be 1 or more present in patient
Risk Factors - Why it could be happending.
Related factors - cannot be medical diagnosis.
Types of Nursing Diagnosis
Actual - Client has a problem right now
Risk For - a problem that is likely to develop based on assessment of risk factors.
Possible - A problem is suspected, but not enough data is available to confirm or rule out.
Wellness - client is currently healthy, but want to achieve higher level of wellness.
Syndrome - multiple nursing diagnosis built together.
Recipe to writing a Nursing Diagnosis
NDX related to secondary to AEB .
NDX related to .
: Establish priorities, esablish client, goals and outcome.
: provide individualized care, client participation, goals that are reasonable.
High - live threatening or something that is very important to the client.
Medium - problems that could result in unhealthy outcome, but not life threatening.
Low - Problems that can be solved easily with little intervention and have little potential to cause dysfunction.
Sometimes clients and nurses have different priorities.
The patient's goal. The changes in the client you hope to achieve.
Goal has to be specific, measurable and realistic.
S - specific
M - Measurable
A - Appropriate
R - Realistic
T - Timely
When writing a goal you need to include who (subject) what (action verb) when (target time) how (perfomrance criteria) and any special conditions.
Consists of developing the plan of care that will assist the client in the area of concern previously identified.
Purposes of a plan
: direct client care, promote coninuity of care, focus charting requirements and allow for delegation for specific activites.
What you do while your planning:
Planning nursing interventions and writing a client plan of care that is client centered and step by step.
Initial and Ongoing Planning
Begins w/ first client contact
Write ASAP after initial assessment
Develop the initial comprehensive care plan
Changes made in the plan as your evaluate client's responses to care.
Purpose: to achieve client outcomes
Should be linked with goal and diagnosis (4 interventions for 1 care plan)
Types of Interventions
Independent Interventions - just yourself
Dependent Interventions - someone else does it
Interdependend interventions (collaborative) lots of people help
Types of Interventions
Psychomotor -- position, apply, insert
Psychosocial -- resolving emotioal, phychological or social problems.
Maintence -- hygeine and skin and other routine nursing care
Surviellance -- detecting changes from baseline
Supervisory -- Oversee clients overall care
Sociocultural -- spend time, culture identity
What is a Nursing Care Plan?
Guides Holistic, goal-oriented care
Individualized for each client
Provides a guide for assessing and charting
Ensures care is complete
Provides continuity of care
Promotes efficient use of nursing efforts
Meets requirements of accrediting agencies.
Types of Evaluation
Structure - attributes of setting or surroundings
Process - nurse's performance
Outcome - client and client fucntion