Chapter 9 Flashcards
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- Cue
- Inference
- Obtained through use of senses
2. Judgement or interpretation of cues
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Structured vs problem focued approach,
Structured uses guidelines to make sure the data is complete
Problem focused begins with problem
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The first step of establishing a baseline is to,
Collect subjective information
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Open ended question
Answer requires more than a few words
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Back channelling
“All right” “go on”
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The last step of assessment should be to,
Communicate the assessment findings either though documentation or verbally
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- Nursing diagnosis
- Medical diagnosis
- Within the scope of nursing practice, often symptoms of disease.
- Actual medical diagnosis, disease
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Defining characteristics
Clinical criteria or assessment findings that support the nursing diagnosis
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Related factor
Identified from the assessment data and is the reason the PT is displaying the diagnosis. Maybe be pathophysiological, treatment related, situational, and maturational
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What is the nursing process?
A critical thinking process that nurses use to apply the best availed evidence to caregiving
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Assessment involves,
Collecting and verifying data.
Analysis of data and development of nursing diagnosis
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Can a nursing diagnosis use a medical diagnosis as the etiology?
Nooo
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Remember … when looking at nursing diagnoses
PES
Problem
Etiology
Symptoms
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Planning involves,
Setting priorities, identifying PT centered goals and expected outcomes
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A PT centered goal is,
A broad statement that describes a desired change in a PTs condition.
Time limited and reasonable
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Expected outcomes
Measurable criteria to evaluate goal achievement
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Dependent nursing interventions require,
An order from a physician or other health care provider
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Nursing interventions classification
(NIC)
- Physiological basic and complex
- Behavioral
- Safety
- Family
- Health system
- Community
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Critical pathways
PT care management plans that provide the interdisciplinary health team with activities and tasks to be put into practice sequentially
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Clinical practice guideline
Set of statements that help nurses and other health care providers make decisions about specific clinical situations
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Standing order
Preprinted document containing orders for conducting procedures for specific PTs with identified clinical problems
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What should you know about delegating care
You are always responsible for making sure that the staff member completes the task according to standard of care
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The evaluation process included what dice elements?
- Identifying evaluative criteria and standards
- Collecting data to determine if the PT met the criteria or standards
- Interpreting and summarizing findings
- Documenting findings
- Terminating, continuing, or revising care
