Ch. 6 Nursing process / M. HLTH NRSG Flashcards
The nursing process
Applicable to every focus of nursing. A helpful tool
Standards of practice that we’ll be doing at unity and other psyc hospitals
- Hist & MSA
- Quick head to toe exam every morning
- Hist: fam, meds, ER assessment
- they might need insulin or an EKG done. Learn how to help!
- EKG: we need a baseline to help detect any heart problems.
- Waist circumference: some meds cause weight gain
expected outcomes (goals)
- SMART goal.
- Realistic
- Short term & long term goal
- Only evaluate short term goals in care plan
Planning
- what are you doing for your patient?
Implementation
- List of goals/interventions is helpful, but use introspection
- We need to know why you’re doing what you’re doing
Nursing case management
- Influences what/how we chart. can put us liable.
- A health delivery process whose goals are to provide quailty health care, decrease fragmentation, enhance the client’s quality of life, and contain cost.
Managed care
A concept designed to control the balance between cost and quality care. Individuals receive care based on need, which is determined by coordinators of the provider-ship.
Concept mapping
Just a different way to care plan
Charting/documentation
- Do what ur nurse does
- EPIC & narrative charting
- Professional. No opinions. Actually write “fuck”
Objective data
are observable and measurable data (signs) obtained through observation, physical examination, and lab and diag. testing
Subjective data
Are infomation from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews