Final Review Flashcards
Nursing Process
Assessment/Data Collection Nursing Diagnosis Planning goals/outcomes care/ interventions Implementation Evaluation
Nursing Process: Assessment
Collect data Review of the clinical record Interview Health history Functional assessment Physical exam Consultation Review of the literature
Subjective: History
Objective: Exam
DATA BASE
Subjective Findings
Objective Findings
Lab/Diagnostic Results
DIAGNOSTIC REASONING
Analyze data and draw conclusions. Formulate hypothesis (“hunch”). Develop “list”… Cluster data in groups Validate data
Nursing Process: Diagnosis
Interpret data Identify clusters of cues – compare clusters Make inferences Validate inferences Identify related factors Document the diagnosis
Clinical judgment about client’s response to “actual” or “potential” health state
TYPES OF NURSING DIAGNOSES
ACTUAL DIAGNOSES
RISK DIAGNOSES
WELLNESS DIAGNOSES
Nursing Process: Planning
Establish priorities
Identify interventions
Document the plan of care
Nursing Process:
Outcome Identification
Identify expected outcomes
Individualize to the person
Realistic and measurable
Include a time frame
Nursing Process:
Implementation
Review planned interventions Schedule and coordinate total health care Collaborate with other team members Supervise implementation of care plan Counsel person and significant others - teaching Involve person in health care plan Refer for continuing care Document care provided
Nursing Process:
Evaluation
Refer to expected “outcomes”
Evaluate individual’s condition and compare actual outcomes with expected outcomes
Identify reasons for failure to achieve “expected” outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care
Evidence Based Practice (EBP)
SYSTEMIC APPROACH TO PRACTICE
EMPHASIZES “BEST EVIDENCE”
(RESEARCH BASED EVIDENCE)
COMBINES “BEST EVIDENCE” WITH…
MEDICAL DIAGNOSES
NURSING DIAGNOSES
Nursing diagnoses
are clinical judgments about a person’s response to an actual or potential health state
Biomedical model
Health as absence of disease
Health and disease are opposite extremes on linear continuum
Disease is caused by specific agents or pathogens
A natural progression to health promotion and disease prevention rounds out our concept of health
Guidelines to prevention emphasize link between health and personal behavior
WELLNESS MODEL
Dynamic processes
Continually moving toward “wellness”
HOLISTIC MODEL
MIND, BODY, SPIRIT = ONE ENTITY
Each part affects the others
HEALTH PROMOTION/DISEASE PREVENTION MODEL
Health and behavior are connected and inter-related”
NURSING MODEL “MIXTURE”
HOLISTIC MODEL
HEALTH PROMOTION/DISEASE PREVENTION
INCLUDES CULTURE, VALUES, FAMILY, SOCIAL ROLES, SELF-CARE BEHAVIORS, ETC.
Data Bases - 4 Types
- Complete Data Base (complete history and physical examination)
- Episodic or Acute Problem-Centered Data Base (focused assessment)
- Follow-up Data Base (re-check)
- Emergency Data Base (emergency assessment)
What is Culture
Culture is composed of all verbal and behavioral systems that transmit meaning
Culture is learned
Culture is shared
Culture is the result of adaptation to the environment
Culture is universal
Culture is dynamic
Becoming Culturally Competent
Cultural Sensitive Cultural Awareness Cultural Knowledge Cultural Skill Cultural Encounter Cultural Desire
Cultural Assessment
Health Beliefs/Practices Religious Beliefs/Practices Language/Communication Family Structure Other Support Systems Dietary Practices/Nutrition Educational Level
Principles of setting priorities
- Airway problems
- Breathing problems
- Cardiac and circulation problems
- Vital sign concerns (high fever)
Guide for cultural care
Preparing:
- discover and understand your own heritage, cultural values, biases, and traditional health beliefs and practices.
- Aquire basic knowledge of cultural values and health/health beliefs and practices for patient groups that you serve
RESPECT
Internal factors
Internal factors are those particular to the examiner, what you bring to the interview.
- Liking Others
- Empathy
- The ability to listen
External Factors
Prepare the physical setting.
- Ensure privacy
- Refuse interruptions
- Dress
- Note taking
PURPOSE OF CLIENT/PATIENT INTERVIEW
Obtain a health history
Begin a relationship with the patient
Teaching and learning
One of the most important parts of health care process.
