Exam 1 Flashcards
Second phase of the nursing process
Diagnosis
The action phase
Implementation
1st phase of the nursing process
Assessment
Based on the pt’s response to health problems
Diagnosis
Includes the history and physical exam
Assessment
Divided into two phases
Planning
Determine whether the outcomes were met
Evaluation
The problem
Diagnosis
Includes test results and lab values
Assessment
Based on evidence-based care standards
Implementation or Planning
Data gathering phase
Assessment
Document actions and patient response
Implementation
Includes outcomes and interventions
Planning
Based on a review of the assessment data
Diagnosis
Care plan is modified
Evaluation
Hypothesis is made
Diagnosis
Delegation occurs
Implementation
Finished product is a care plan
Planning
4 purposes of Nursing
Promote Health
Prevent Illness
Restore Health
Advocacy
Promote Health
Education, encouragement, diet plans, exercise
Prevent Illness
Hygiene, Dr’s 1st set of eyes, vaccinations, screenings
Restore Health
Position changes, bandage changing
Advocacy
When pt is in pain, notice cues and verbal changes, providing resources
What is the ANA?
American Nurses Association
Code of ethics, scope standards, advocacy, ethics, quality of practice
What is PT, OT, and RT?
Physical Therapy- focuses on improving pt body movement
Occupational Therapist- focuses on pts ability to perform daily activities
Respiratory Therapist- give pts oxygen, lung performance
Roles and Functions of the Nurse
Direct care provider . Leader
Communicator Change agent
Teacher/educator. Manager
Client advocate. Case Manager
Counselor. Research consumer
Definition of the Nursing Process
A systematic problem-solving process for the delivery of care
Purpose of the Nursing Process
To help the nurse provider goal-directed, client-centered care
What are the phases of the Nursing process?
1. Assessment
2. Diagnosis
3a. Planning Outcomes
3b. Planning Interventions
4. Implementation
5. Evaluation
1st Phase of Nursing
Assessment- Gather data
Asses the patient
Subjective/objective
Primary/secondary
Health Hx
2nd Phase of Nursing Process
Diagnosis-
Identify pts health needs
Dx from NANDA
Prioritize (Maslows ABCs)
. Pick one
. Nursing Dx
3rd Phase of Nursing Process
A. Planning outcomes-
. Decide goals to achieve
(measurable)
B. Planning interventions-
Chose intervention to achieve goals
4th Phase of Nursing Process
Implementation-
Document
Action phase. Do it!
Delegations
5th Phase of the Nursing Process
Evaluation-
Final phase
Judge if actions successfully treated pts problems
Yes/No- Assessment
Clinical Judgement Model
NCJMM
Built on & expands nursing process
Evidence based
Identifies 6 cognitive skilled needed to make clinical judgements
NCJMM 6 cognitive skills
Recognize cues
Analyze cues
Prioritize hypotheses
Generate solutions
Take action
Evaluate Outcomes
NCJMM Step 1
Recognize Cues (Assessment)-
Data gathering
Subjective- what pts says (sx)
Objective- what professionals say (observations & labs, CT, MRI)
Primary (pt)
Secondary (spouse, health record)
Different types of assessments
Initial- 1st appointment, ED
Ongoing- CA, vitals q 4hrs, pain management
Comprehensive- whole body, spiritual
Focused- ABD Pain (start with GI)
Special needs- nutritional, cultural, psychosocial, family, wellness
When do you validate data?
Subjective & objective do not agree
Data falls out of nl range
Pts statement changes
*Once you get your data, document it*
NCJMM step 2
Analyze cues/hypotheses (Diagnose)-
Identify patterns
Draw conclusion to identify pts health status
Medical Diagnosis
Describes illness, injury, or disease
Remains constant unless cured
Made by Drs, NP, and PAs
Nursing Diagnosis
Focuses on responses or health problems
(N/V now under control… can change)
NANDA nursing Dx
(Self care deficit, impaired urinary elimination)
Components of NANDA Nursing Diagnosis
Type of Nursing Dx-
Problem focused, health promotion, at risk
Problem-
NANDA Dx
Etiology- (r/t related to)
Related or risk factor or cause
Signs & Symptoms- (AEB as evidence by)
Cluster of symptoms that support Dx
