Class 7-Nursing Process Flashcards
Nursing process
framework for professional nursing practice/setting a standard of care
Standardized nursing language (NANDA North American nursing diagnosis association)
-defines nursing’s contribution and impact in healthcare. defines what nurses do
-gives nurses more evidence based outcomes and interventions
-easily integrated into EMR
-standardizes knowledge for nursing curriculum (QSEN)
-promotes nursing research
think like a nurse to develop clinical judgement-why learn it?
-prepare for NCLEX
-transform thinking into clinical judgement
-become a self directed thinker
-becoming resilient
-reduce errors in healthcare setting
NGN (next generation) clinical judgement measurement model
-recognize cues
-analyze cues
-prioritize hypotheses
-generate solutions
-take actions
-evaluate outcomes
recognizing cues OR getting the information/assessing
-determine what information you need
-use multiple sources
-eliminate preconceived ideas
-scan the environment
-identify signs and symptoms
-assess systematically and comprehensively
-ensure that you collect accurate information
alignment of the clinical judgement model and the nursing process
-CJM (clinical judgement model)
-nursing process
CJM
-getting the information
-making meaning of the information
-determine actions to take
-take action
-evaluate outcomes and your thinking
Nursing process
-assessment
-diagnosis
-planning
-implementing
-evaluating
ADPIE-nursing process
Assessment
diagnosis (identify problem)(actual=3 part; risk=2 part)
planning (patient outcomes; nursing interventions)
implement
evaluation (patient outcomes)
LOOK AT SLIDE 8
a nursing care plan allows the nurse to:
-INDIVIDUALIZE CARE that maximizes outcome achievement
-SET PRIORITIES
-FACILITATE COMMUNICATION among nursing personnel and colleagues
-PROMOTE CONTINUITY of high-quality, cost-effective care
-EVALUATE PATIENT RESPONSE to nursing care
-CREATE A RECORD used for evaluation, research, reimbursement, and legal reasons
characteristics of nursing assessments
-purposeful
-prioritized
-complete
-systematic
-accurate
-relevant
-recorded in a standard manner
Types of assessment
initial
-admission: in depth; set base line for hospitalization
-shift: baseline for shift; a bit quicker
focused
time-lapsed: coming back at certain time point; pre determined; after specific amount of time; usually more outpatient
sources of data for assessment
-patient
-family and significant others
-patient record
-other healthcare professionals
types of assessment data
subjective
-what the patient feels or says
objective
-measurable and observable
how the phases of assessment set the stage for diagnosis
assessment
-collecting data
-identifying cues and making inferences
-validating data
-clustering related data and identifying patterns
-reporting and recording data
(identify a problem_
clinical reasoning
-(analyzing, synthesizing, reflecting, making judgements and drawing conclusions)
diagnosis
diagnosis
nursing diagnosis: a clinical judgement about an individual’s responses to actual or potential health problems
nursing diagnosis provides the basis for selection of patient outcomes and the nursing interventions to achieve the set outcomes
steps in diagnostic process
-create a list of suspected problems
-name actual and potential problems/diagnoses and clarify what is causing or contributing to them
-determine risk factors that must be managed for a risk DX
-confirm defining characteristics for an actual DX
-prioritize nursing diagnoses
nursing diagnosis
-no problem
-problem focused diagnosis*
-risk diagnosis*
-health promotion diagnosis
-syndrome diagnosis
***types of NSG DX used in the first semester
actual problem 3 part nursing diagnosis
problem related to (r/t) etiology (cause or contributing factors) as evidence by (AEB) defining characteristics (subjective and objective data that support the problem you identified)
impaired nutrition less than body requirement R/T decreased desire to eat AEB BMI 13, Pre-albumin of 15 (norm 40-100), patient consumes only 5% of meals X 5 days
see slide 18
etiology’s (cause of problem)
factors that appear to show some type of patterned relationship with the nursing diagnosis. such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. ONLY PROBLEM FOCUSED NURSING DIAGNOSES AND SYNDROMES MUST HAVE RELATED FACTORS.
adding secondary to the etiology for clarification
pain r/t tissue damage 2ndary to MI AEB patient complaints of pain 8/10 substernal and pressure like, relieved with NTG
actual nursing diagnosis-3 part statement
Problem; (drives patient outcomes)
R/T
Etiology (cause): (drives nursing interventions)
AEB
defining characteristics (s & s)
at risk nursing diagnosis
-a clinical judgement concerning the vulnerability of an individual for developing an undesirable human response to health conditions or life processes (no defining characteristics)
-2 part diagnosis
-problem statement AEB risk factors
risk for falls AEB the following risk factors: previous history of falls
risk factors
-environmental factors and physiological, psychological, genetic, or chemical elements that increase the vulnerability of an individual, family, group, or community to an unhealthy event. only risk diagnoses have risk factors
nursing diagnosis V medical diagnosis
-medical DX: myocardial infarction
-nursing diagnosis=response to the medical diagnosis (pain, fear, anxiety)
-pain r/t tissue damage AEB patients reports of substernal chest pain rated 10/10
-pain r/t tissue damage 2ndary to MI AEB patients reports of sub-sternal chest pain rated 10/10
-fear r/t hospitalization AEB patients statements “I’m afraid that I’m going to die”
nsg dx versus medical dx
nursing diagnosis
-ineffective airway clearance
-disturbed body image
-risk for unstable blood glucose
-impaired urinary elimination
-self-care deficit: dressing
medical diagnosis
-pneumonia
-amputation
-type 2 diabetes mellitus
-post-op prostatectomy
-cerebrovascular accident
Maslow’s hierarchy (how to set priorities)
-physiologic needs
-safety and security
-love and belonging
-self-esteem
-self-actualization
physiologic needs
-oxygen
-food
-elimination
-temperature control
-sex
-movement
-rest
-comfort
safety and security
safety from physiologic and psychological threat; protection, continuity, stability, lack of danger
love and belonging
-affiliation
-affection
-intimacy
-support
-reassurance
self-esteem
sense of self worth, self respect, independence, dignity, privacy, self reliance
self-actualization
recognition and realization of one’s potential, growth, health, and autonomy
benefits of nursing diagnoses
-individualizing patient care
-defining domain of nursing to health care administrators, legislators, and providers
-seeking funding for nursing and reimbursement for nursing services
common errors
the problem and the etiology are the same
-altered comfort related to pain (incorrect)
-altered comfort related to tissue damage secondary to surgery
