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- systemic collection, verification, organization, interpretation and documentation of data performed on every pt used to identify the current health status
- provides a baseline for future care and can be evaluated
- used to evaluate the effectiveness of the current plan
- COMPREHENSIVE; complete health hx, lab and diagnostic tests; usually completed on admission but is dependent on the pt's status
- FOCUSED; on a particular need or risk; usually focuses on one body system; used where short stays are anticipated ie outpatient facilities
- ONGOING; intervention includes ongoing assessment, after we have identified the problem we continue to assess the pt responses to actions, the frequency depends on the severity of the problem
- EMERGENCY; rapid assessment, the pt has a life threatening problem
Back Channeling is...
- active listening prompts such as "all right," "go on," or "uh-huh."
- these indicate that you have heard what the pt said and you are attentive to the full story
Close-ended questions are...
questions that limit the pts response to one or two words
information about the pt's perceived needs, health problems and responses to the problems
your judgement or interpretation of cues ( cues are information that you obtain through the use of senses)
- an organized conversation with the pt.
- consists of three phases; orientation, working and termination.
Nurse-Client relationship is...
established by laying the groundwork for the nurse to u/s the clients needs and begin the relationship that allows the pt to become a partner in the decisions about care
Nursing Health Hx is...
- done during the working phase
- includes data about the clients current level of wellness, including a ROS, family and health hx, sociocultural hx, spiritual health and mental and emotional reactions to illness
Objective data is...
- observations made and data measured and collected by the nurse
- can also be measured by others
- Primary Source; what you (RN) measured or saw
- Secondary Source; lab results or diagnostic tests
- *we look to verify subjective data with objective findings.*
Open-Ended questions are...
- questions that encourage the pt to answer the question in more then 1 or 2 words.
- encourages discussion and builds trust with the pt
Subjective Data is...
- pt or families perception of the health problem gathered from the interview
- this data is not measurable, no one else can quantify or measure it
- Primary Source; is what the pt tells you
- Secondary Sources; other people report it, such as spouse, friends or family
Actual Health Problems are...
- problems that actually exist
- ex a pt with a break in their skin actually has impaired skin integrity
- there are defining characteristics that lead you to conclude what the actual problem is
At Risk Health Problems are...
- indicated that there is potential for a problem
- if a pt has a hx of falls they are more at risk for falls than someone who does not have that hx
Defining Characteristics are...
- the abnormal data that we collected that supports the dx
- can be objective or subjective
- the clinical criteria of assessment findings that validate the presence of a diagnostic category
- clinical criteria are objective and subjective signs and symptoms or risk factors
Diagnostic Process is...
- use of the assessment data that you collected about a pt to logically explain a clinical dx
- in this case the nursing dx
- the steps include data clustering, identifying pt needs and formulating the dx
- the related factor
- associated with the clients actual or potential response to the health problem
- what we aim to change with the nursing interventions
Medical Dx is...
- the identification of a disease condition based on a specific evaluation of physical signs and symptoms, the pt's medical hx and the results of diagnostic tests and procedures
- physicians are licensed to treat diseases or pathological processes described in medical diagnostic statements
Nursing Dx is...
- a clinical judgement about an individual, family or community responses to actual and potential health problems or life processes
- it is a statement that describes the pt's actual or potential response to a health problem that the nurse is licensed to treat
North American Nursing Diagnosis Associations is...
- a professional association
- purpose is to develop, refine and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
- provides a common language for the health problems that nurses deal with
Client-Centered goals are...
- specific and measurable behavior or response that reflects the pt's highest possible level of wellness and independence in fx
- ex. pt will perform self-care hygiene independently or pt will remain free of infection
Collaborative Interventions are...
- also called interdependent nursing interventions
- are therapies that require the combined knowledge, skill and expertise of multiple health care professionals
Nurse-Initiated Interventions are...
- independent nursing interventions
- actions that the nurse initiates
- do not require a direct order from another health care professional
- autonomous actions based on scientific rationale
Physician-Initiated Interventions are...
- dependent nursing interventions
- actions that require and order from a physician or another health care professional
- based on the MD's response to treat or manage a medical dx
- as a nurse you carry out the the providers written or verbal orders
- ex. med administration, implementing an invasive procedure, changing a dressing or preparing the pt for diagnostic test
Standard of care is...
- minimum level of care accepted to ensure high quality of care to clients
- define types of therapies typically administered to clients with defined problems or needs
Define the nursing process.
- a professional nurses approach to identify, diagnose and treat human responses to health and illness
- this process enables the nurse to organize and deliver nursing care
List 5 components of the nursing process in their appropriate sequence.
Define each component.
- Assessment: data collection
- Diagnosis: a statement that describes the pt's actual or potential response to a health problem that the nurse is licensed or competent to treat, analyze and interpret and form clusters of data
- Planning: determining how to prevent, reduce or resolve the identified pt problems; determine pt centered goals and expected outcomes, establish priorities and select appropriate interventions
- Implementation: methods to achieve the goals of nursing care; assist in the performance of ADL's, counseling and education, provide direct nursing care, supervise and evaluate the work of other staff; can be either dependent, dependent or interdependent
- Evaluation: measures the degree to which goals and outcomes have been achieved
Differentiate b/t subjective and objective data.
subjective is what the pt tells you and objective is what you observe
Describe the various sources of data that can provide information about a pt.
- Family or significant other
- Healthcare team members
- Medical records
- Other records (education, military or employment)
- Literature review
- Nurse's experience
Identify the methods of data collection the nurse uses to establish a data base.
- Nursing health hx
- Physical exam
- Lab and diagnostic tests
Discuss the types in interview techniques.
- Open ended questions
- Closed ended questions
- Back channeling
- Problem seeking interview (focusing in on the stated problem)
Define the phases of the interview.
- Orientation Phase: before beginning the nurse reviews the purpose for the interview, the types of data to be obtained and the methods most appropriate for conducting the interview; establishing the nurse- client relationship by laying the groundwork for the nurse to u/s the clients needs and begin the relationship that allows the pt to become a partner in the decisions about care
- Working Phase: the nurse asks questions to form the database from which the nursing care plan will be developed. this is where the 4 interview techniques are implemented
- Termination Phase: the client should be given a clue in the interview is about to end. the interview ends in a friendly manner and the nurse specifically indicates when there will be additional contact
List the elements of a nursing health hx.
- Biographical information
- Reason for seeking health care
- Client expectations
- Present illness
- Family hx
- Environmental hx
- Psychosocial hx
- Spiritual health
- Physical exam
- Diagnostic and lab data
Differentiate b/t a nursing dx and a medical dx.
- RN dx focuses on and defines the nursing needs of the pt where as the MD dx identifies a specific disease state.
- The MD focus is on dx and tx of disease where as the RN cannot tx a medical dx but they can tx the effects of the medical dx
- ex- a RN cannot cure lung cancer but we can tx the effects of the lung cancer
Describe the components of a nursing dx.
- Diagnostic process: gathering the assessment database, identifies actual or potential client problems
- Analyzing and Interpreting data: look for clusters in the assessment data
- Identifying client needs: analyze the pt's general health care problems, move from general to specific, could be an actual or at risk problem
- Formulating the nursing dx: once data and clusters are sorted and the pt needs are identified the RN is ready to form the dx
List the steps of the nursing dx process in their appropriate sequence.
- Interpretation of data
- Identification of pt needs
- Formulation of the nursing dx
Determine the relationship b/t defining characteristics and a nursing dx.
defining characteristics SUPPORT the nursing dx
Define and discuss goals of care of the planning component of the nursing process.
- goals of care planning are guideposts to the selection of nursing interventions and criteria in the evaluation of nursing interventions
- the nurse uses critical thinking to develop goals and expected outcomes that are relevant to the pt needs as evidenced by the assessment database and the nursing diagnosis
- there are long term and short term goals
Define and discuss expected outcomes.
- expected outcomes are specific step by step objectives that lead to attainment of the goals and the resolution of the etiology for the nursing dx.
- an outcome is a measurable change in the pt's status in response to nursing care
- the EO's determine whether a goal has been met
List the guidelines for writing and outcome statement.
- Client-centered factors: reflect expected client behavior and responses to intervention; focuses on the pt and specific dx
- Singular factor: each goal and EO addresses only one behavioral response
- Observable factors: EO's should be observable, can also be physiological finding, knowledge or behavior
- Measurable factor: allows the RN to objectively quantify changes in the pt's status
- Time-limiting factors: indicate when the expected outcome should occur, determines whether progress is being made at a reasonable rate
- Mutual factors: when pt and RN agree on the goal setting and outcome there is an increase in the pt's motivation and cooperation
- Realistic factors: short-term realistic goals and EO's quickly provide the RN and the pt with a sense of accomplishment
Discuss the purpose of a nursing care plan.
- NCP is a written guideline for pt care
- NCP's document the pt's health care needs and communicate to other nurses and health care professionals the pt's pertinent assessment data, problems and therapies
- NCP's decrease the risk for incomplete, incorrect or inaccurate care
- the care plan is organized so the RN can quickly identify nursing actions to be given
- it makes possible for the coordination of nursing care, subspecialty consults and the scheduling of diagnostic tests.
- it organizes information exchanged by nurses at end of shift reports, transfers and discharges.
- the complete care plan is the blueprint for nursing action
- it provides direction for implementation of the plan and a framework for evaluation of the pt's response to the nursing actions
- Critical pathways allow staff from all disciplines (medicine, nursing, pharmacy and social work) to develop integrated care plans for a projected length of stay or number of visits for pt's with a specific case type
Describe the five steps of the nursing implementations process.
- reassess the pt
- review and revise the existing NCP
- organize resources and care delivery
- anticipating and preventing complications
- implementing nursing interventions
Identify 5 different methods for carrying out the implementation process.
- assisting with ADL's
- providing direct nursing care
- compensation for adverse reactions
- preventative care
- lifesaving measures
- delegating, supervising and evaluating the work of others
Outline the steps needed for the objective evaluation of pt expected outcomes.
- examine the goals statement to identify the exact desired pt behavior or response
- assess the pt for the presence of that behavior or response
- compare the established outcome criteria with the behavior or response observed
- if there is no agreement or partial agreement between the expected outcome and the observed outcome then determine what are the barriers? why did they not agree? what needs to be altered?
Describe ways in which the nurse consults and collaborated with other health care personnel while using the nursing process.