Ch. 8 Flashcards
Nursing Process
a professional nurse approach to identify diagnosing, and treating human responses to health and illness( American Nurses association 03’)
The Nursing process includes which 5 steps?
- Assessment
- Nursing diagnosis
- planning
- Implementation
- Evaluation
Assessment
is the deliberate and systematic collection of data about a patient.
Nursing diagnosis
is a clinical judgment about individual. family or community responses to actual and potential health problems or life processes.
Planning
set goals of care and desired outcomes and identify appropriate nursing actions
implement
perform the nursing actions identified in planning
Evaluate
determine if goals met and outcomes achieved.
Cue
information that you obtain through use of senses.
Inference
is your judgment or interpretation of those cues.
Subjective data
patients verbal descriptions of health care problems.
Objective data
are observations or measurements of a patient’s health status.
Medical diagnosis
is the identification of a disease condition based on an evaluation of physical signs, symptoms, history, and diagnostic tests and procedures.
A collaborative problem
is an actual or potential physiological complication that nurses monitor to detect the onset of changes in a patient’s status
An interview consists of which 3 phases?
Orientation, working and termination.
NANDA International 2009
The North American Nursing Diagnosis Association “To develop, refine, and promote a taxonomy (model) of nursing diagnostic terms of general use for professional nurses”.
Data clusters
organizing and analysis of data collection and keeping in mind the patient’s response to illness.
Data analysis
involves recognizing patterns or trends in the clustered data, comparing them with standards, and then coming to a reasoned conclusion about the patient’s response to a health problem.
NANDA-I has identified 5 types of nursing diagnosis, what are they?
Actual Health promotion Risk Syndrome Wellness
Name the 2 part form of the nursing diagnosis?
Diagnostic label
Related factor
Diagnostic label
is the name of the nursing diagnosis within the NANDA-I taxonomy. It describes the essence of a patient’s response to health condition in as few words as possible.
Related factor
a condition or etiologic factor that appears to show some type of patterned relationship with the nursing diagnosis.
Etiology
is always within the domain of nursing practice and a condition that responds to nursing interventions.
Definition
NANDA-I approves a definition for each diagnosis following clinical use and testing.
Risk factors
environmental, physiological, genetic, or chemical elements that increase the vulnerability of an individual, family, or community, to an unhealthful event.
Documentation
after identifying a patients nursing diagnosis, list them on the plan of care, whether this is in the form of computerized care plans or a problem list on the nursing kardex.
Planning
involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing nursing interventions.
Scientific rationale
support for why a specific nursing action is chosen.
There are 3 categories of nursing interventions:
Nurse-initated.
physician initiated.
collaborative interventions.
Nurse initiated
independent-nursing interventions that nurses initiate on their own to act on a patients behalf.
Physician-initiated interventions
dependent nursing interventions or actions that require an order from a physician or another health care professional.
Collaborative interventions/ interdependent interventions
are therapies that require the combined knowledge and skill, and expertise of multiple health care professionals.
Interdisciplinary conferences
Bring professionals from all disciplines involved in the patient’s care to the table so that together they can establish and execute the most appropriate plan of care.
When choosing interventions consider 6 factors:
- characteristics
- expected outcomes and goals.
- evidence base
- feasibility of the intervention
- acceptability to the patient
- your own competency.
NIC
The Iowa intervention project developed a set of nursing interventions that provides a level of standardization to enhance communication of nursing care across all health care settings and to compare outcomes.
Concept map
provides a visual reception of the complex level of thinking that nursing care requires.
Critical pathway
Multidisciplinary, outcome-based care plan.
Consultation
is a process in which you seek expertise of a specialist, such as your nursing instructor or a clinical nurse specialist, to identify ways to handle problems in patient care management or in the planning and implementation of therapies.
Implementation
is the performance of nursing interventions necessary for achieving the goals and expected outcomes of nursing care.
A nursing intervention
is any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes.
Direct nursing interventions
are treatments performed through interactions with patients.
Indirect care interventions
are treatments performed away from the patient but on behalf of the patient or group of patients. EX: delegation, environmental safety, infection control, documentation and collaboration.
A clinical guideline
or protocol is a document that guides decisions and interactions for specific health care problems or conditions, such as treatment for a patient who has had a stroke or the administration of chemotherapy.
Standing order
is a preprinted document containing orders for conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients with identified clinical problems.
Cognitive skills
involve the application of critical thinking in the nursing process. EX:Recognizing the patients need for nutritional instruction.
Interpersonal skills
effective for nursing action, develop a trusting relationship, express a level of caring and communicate clearly with patient and family. EX:Completing a health history. Providing emotional support for family.
Psychomotor skills
requires the integration of cognitive and motor activities. EX:preparing and administering an injection. Changing a surgical dressing.
