EXAMS 2 Flashcards
what does nursing care plans provide
provide a means of communication among nurses, their patients, and other healthcare providers to achieve health care outcomes.
what is Informal nursing care plan
a strategy of action that exists in the nurse’s mind
what is formal nursing plan
a written or computerized guide that organizes information about the client’s care.
what are Nursing Care Plans Concept Maps
Utilize the Nursing Process to construct an individualized plan of care for a patient based on a critical analysis of patient assessment data
what is the Nursing Process
Systematic method of giving humanistic care that focuses on achieving outcomes in a cost effective manner.
characteristics about nursing care plans
- Written guidelines for client care
- Organized so nurse can quickly identify nursing actions to be delivered
- Coordinates resources for care
- Enhances the continuity of care
- Organizes information for change of shift report
The Nursing Process is a Systematic Five Step Process what are they?
ADPIE
Assessment Diagnosis Planning Implementation Evaluation
what is ASSESSMENT of the nursing process
What data is collected?The first step of the nursing process.
- Gather data.
- Important information is through an interview.
- Physical examinations.
- Includes reviewing patient’s health history, surgical history, family history, and any general
includes manifestations of the pain. using nursing process to know they have a blocked artery etc
what is DIAGNOSIS of the nursing process
what is the problem?
USING OF JUDGEMENT TO IDENTIFY POTENTIAL CAUSE, HEALTH NEEDS OR CONDITIONS
- Diagnosing involves a nurse making an educated judgment about a potential or actual health problem with a patient.
- More than one diagnoses are sometimes made for a single patient.
- not every
nursing diagnosis is accompanied by potential complications
what is PLANNING in the nursing process
How to manage the problem?
- Each problem is committed to a clear, measurable goal for the expected beneficial outcome
- S.M.A.R.T Goals
S.M.A.R.T Goals
Specific
Measurable
Achievable
Realistic Timely
IMPLEMENTATION of the nursing process
- Putting the plan into action
- Interventions should be specific to each patient and focus on achievable outcomes.
- Actions associated in a nursing care plan include monitoring the patient for signs of change or improvement, directly caring for the patient, educating and guiding the patient about further health management, and referring or contacting the patient for a follow-up.
EVALUATION of the nursing process
Did the plan work?
- Once all nursing intervention actions have taken place evaluate what was the impact on the patient.
- Did the patient’s condition improved, the patient’s condition stabilized, or the patient’s condition worsened.
- If goals were not met, the nursing process begins again from the first step
Using the Nursing Process for Care Plans
- Requirement set forth by national practice standards (ANA, TJC)
- Basis for NCLEX exams
- Based on principles and rules that promote critical thinking in nursing
5 Activities Needed to Perform a Systematic Assessment
- Collect data
- Verify data
- Organize data
- Identify Patterns
- Report & Record data
Comprehensive Data CollectionComprehensive Data Collection
- Begins before you actually see the patient (Nurse report, Chart reviews)
- Continues with admission interview and physical assessment once you meet patient.
- Other information resources include: family, significant others, nursing records, old medical records, diagnostic studies, relevant nursing literature.
- Consider age, growth & development
What’s Important Data?
Name, age, gender, admitting diagnosis Family or support person present Appropriate to share information Medical/surgical history, chronic illnesses Advanced Directives, DNR, Healthcare Surrogate Laboratory Data/Diagnostic tests Medications current and past Allergies and what happens? Psychosocial/Cultural Assessment Emotional state Comprehensive Physical Assessment
Comprehensive Physical Assessment
- Vital signs
- Height & weight
- Review of systems (neurological/mental status, musculoskeletal, cardiovascular, respiratory, GI, GU, skin and wounds.
- Standardized risk assessments
importance of clustering data
Clustering data helps maintain a nursing focus, allows patterns to be recognized
- Cluster data into groups according to a nursing (Maslow’s Basic Human Needs Model)
how should clustering be done
Cluster by body system or need deficit
- Example: All information gathered regarding nutritional status may help to identify nutritional alterations
PRIOTIZING physiological needs
- Airway
- Breathing
- Circulation
what are the Novice nurse responsible for
- Novice nurse responsible for recognizing health problems, anticipating complications, initiating actions to ensure timely and appropriate treatment.
what is the APN role
Laws & standards continue to change to reflect how nursing practice is growing
what is Nursing Diagnosis
Nursing diagnosis provide a basis for selection of nursing interventions so that goals and outcomes can be achieved
Identifying Nursing Diagnosis
- Common language for nurses
- A clinical judgment about an individual, family or community response to an actual or potential health problem or life process
- NANDA list of acceptable diagnoses, updated every 2 years.
Diagnostic Reasoning
- Apply critical thinking to problem identification
- Requires knowledge, skill, and experience
- Big Picture
Fundamental Principles of Diagnostic Reasoning
- Recognize diagnoses
- Keep an open mind
- Back up diagnosis with evidence
- Intuition is a valuable tool for problem identification
- Independent thinker
- Know your qualifications & limitations
the 4 types of nursing diagnosis
- Actual (Problem-Focused)
- Risk
- Health Promotion - Syndrome.
difference between actual and potential diagnosis
ACTUAL: actual evidence of signs/symptoms of diagnosis exist. (Fluid Volume Deficit)
POTENTIAL/RISK: client’s data base contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity)
writing a nursing diagnosis
- Don’t state 2 separate problems in one diagnosis
- Use accepted qualifying terms (Altered, Decreased, Increased, Impaired)
- Don’t use Medical Diagnosis (Altered Nutritional Status related to Cancer)
- refer to NANDA list in a nursing text books
Planning: 4 Part Process
- Set your priorities of care, what needs to be done first, what can wait.
- Apply Nursing Standards, Nurse Practice Act, National practice guidelines, hospital policy and procedure manuals.
- Identify your goals & outcomes, derive them from nursing diagnosis/problem.
- Determine interventions, based on goals.
- Record the plan (care plan/concept map)
example of short term goal
Client will ambulate down the hall within 2 days.
example of long term goal
Client will walk the length of the hallway independently by the end of 2 weeks
Achieving Goals/Outcomes
- Be realistic in setting goals. (look at overall health state, growth & development level, prognosis)
- Set goals mutually with client
- Goals should be measurable, use measurable, observable verbs
- Identify one behavior per outcome
- When indicated use short-term vs. long tern goals
Determining Interventions
Interventions will be collaborative, combining nursing actions and physician orders.
EXAMPLE: PATIENT WITH INEFFECTIVE AIRWAYS CLEARANCE RELATED TO INCISIONAL PAIN
- Nursing Actions: Ascultate breath sounds every four hours, Assist with coughing and deep breathing every hour etc.
Physician orders: pain medication, activity orders
achieving outcomes
- Identify one behavior per outcome
- Be realistic in setting goals. (look at overall health state, growth & development level, prognosis)
- Set goals mutually with client
- Goals should be measurable, use measurable, observable verbs
Implementation
- Putting your plan into action
- Set priorities after report
- Assess and reassess
- Perform interventions
- Chart client responses
- Give report to next shift
Implementation of Nursing Interventions
- Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed
- Action taken by nurse
Types of Nursing Interventions
Protocols
Standing Orders
what is protocol of nursing interventions
Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation
what is standing orders of nursing intervention
Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition
Implementation Process involves:
- Reassessing the client
- Reviewing and revising the existing care plan
- Organizing resources and care delivery (equipment, personnel, environment)
Evaluation of Goal Achievement
- Measures and Sources: Assessment skills and techniques
- As goals are evaluated, adjustments of the care plan are made
- If the goal was met, that part of the care plan is discontinued
- Redefines priorities
Concept Map Care Plans
- Innovative approach to planning & organizing nursing care.
- Essentially a diagram of patient problems and interventions
- Ideas about patient problems and interventions are the “concepts” to be diagrammed.
Enhances critical thinking and clinical reasoning - Used to organize patient data, analyze relationships, establish priorities
Theoretical Basis of Concept Maps
- Roots in education and psychology
- Also known as mind maps, cognitive maps
- Concept mapping requires critical thinking
- New knowledge is built on preexisting knowledge, new concepts are integrated by identifying relationships
Steps in Concept Map Care Planning
Develop a Basic Skeleton Diagram Analyze and Catagorize Data Analyze Nursing Diagnoses Relationships Identifying Goals, Outcomes, & Interventions Evaluate patient responses
Maslow’s Hierarchy of Human Needs
- Physiologic needs
- Safety needs
- Love and belonging needs
- Self-esteem needs
- Self-actualization needs
Physiologic needs maslow
oxygen food elimination shelter rest/bed/sleep temperature
what is initial comprehensive assessment
performed shortly after the patient is admitted to a health care agency or service
what is the purpose of initial assessment
The purpose of
the initial assessment is to establish a complete database for problem identification and care planning.
what is focused assessment
problem (sickness) that has already been identified.
- It is also used to identify new or overlooked problems
- In focused assessments, the nurse determines whether the problem still exists and whether the status of the problem has
changed.
what is Emergency Assessment
When a life-threatening physiologic or psychological crisis occurs. CPR
- Emergency assessments are not used to establish a database for medical care, practice
assessment skills, or help a physiologic process (such as breathing).
what is time lapsed assessment
compare a client’s current status to baseline data obtained earlier
- CURRENT HEALTH STATUS
what is subjective date
- perceived only by the affected person
- Subjective data are those which the client can feel and describe.
- cant be verified by the nurse
what is objective data
Objective data are observable and measurable data that can be seen, heard, or felt by someone other than the person
experiencing them.
can be verified by someone else
what is the nursing diagnosis
person response to medical diagnoses
what is Validation
Validation is the act of confirming or verifying to plan appropriate nursing care
what is inference
making a judgment that the client is confused is an inference.
An inference must be validated with subjective and/or
objective data cues.
composing a nursing diagnosis statement
after the etiology, use “as defined by”
Risk nursing diagnoses are
- clinical judgments that an individual, family, or community is more vulnerable to develop
the problem than others in the same or similar situation - not every
nursing diagnosis is accompanied by potential complications.
identify etiologies
factors that contribute to or
cause health problems
Collaborative problems
nurses monitor to detect onset or changes in status.
Nurses manage collaborative problems by using physician-prescribed and nursing-prescribed interventions to minimize
the complications of the event
common error made when writing client outcomes
expresses the client outcome as a nursing intervention
critical thinking
“Which problems require my immediate attention or that of the team?”
- “Which problems are most
important to the client?”
discharge planning
Begins when the patient is admitted for treatment
teaching and counseling
Cognitive: outcomes
describes increases in patient knowledge or intellectual behaviors
Psychomotor: outcomes
describes patient’s achievement of new skills
Affective: outcomes
describes changes in patient values, beliefs, and attitudes
Parts of a Measurable Outcome
subject Verb Conditions Performance criteria Target time
Collaborative interventions are treatments initiated by
other providers, such as pharmacists, respiratory therapists,
physical therapists, and other members of the health care team
