FUNDA LEC NURSING AS SCI (2) Flashcards
because it involves the systematic application of scientific principles and methods to promote health, prevent disease, and alleviate suffering. Nursing science is based on the study of the principles and application of nursing, which includes the understanding of human physiology, psychology, and sociology, as well as the development of theories and models that guide nursing practice.
nursing as a science
Nursing involves a systematic approach to client care, which includes assessment, diagnosis, planning, implementation, and evaluation. This systematic approach is characteristic of scientific inquiry.
systematic approach
Nursing practice is grounded in evidence from research and theory, ensuring that interventions are informed by the best available knowledge.
evidence-based practice
Nursing science is built on theoretical foundations that provide the framework for understanding human behavior, health, and disease. These theories are developed through rigorous research and testing, ensuring that they are grounded in empirical evidence.
theoretical foundations
Nursing science applies scientific principles from various disciplines, such as biology, psychology, sociology, and physics, to understand and address the complex needs of clients.
application of scientific principles
Nursing science is a dynamic field that is constantly evolving through ongoing research, testing, and refinement of theories and practices. This continuous improvement ensures that nursing practice remains evidence-based and effective.
continuous improvement
purpose of assessment
to identify the client’s health problems and determine their needs
Gathering information from the client, family, and caregivers through interviews, questionnaires, and other communication methods.
subjective information
Conducting physical examinations, laboratory tests, and other diagnostic procedures to gather objective data about the client’s health status.
objective information
is the process of gathering information about the client’s health status. It is a critical step in the nursing process, as it provides the foundation for developing a comprehensive plan of care.
assessment
the purpose of assessment is to
gather information,identify health problems, develop plan of care
subjective assessment involves
health history, interviews and questionnaires
SCENARIO: A client is admitted to the hospital with a diagnosis of pneumonia. The nurse conducts the following assessment:
Health History: The client reports a history of chronic obstructive pulmonary disease (COPD) and has been experiencing shortness of breath for several days.
Interviews: The client reports feeling fatigued and experiencing chest pain.
Questionnaires: The client reports a pain level of 8 out of 10.
SUBJECTIVE ASSESSMENT
objective assessment includes
physical examination and diagnostic test
SCENARIO: A client is admitted to the hospital with a diagnosis of pneumonia. The nurse conducts the following assessment:
Physical Examination: The client’s vital signs are: temperature 38.5°C, pulse 120 beats per minute, and blood pressure 140/90 mmHg. The client’s lung sounds are wheezy, and the client has a cough.
Diagnostic Tests: The client’s laboratory tests show elevated white blood cell count and C-reactive protein levels, indicating an infection.
OBJECTIVE ASSESSMENT
is the process of identifying the client’s health problems and determining the focus of nursing interventions. It is a critical step in the nursing process, as it helps nurses to prioritize their care and develop effective interventions to address the client’s needs.
nursing diagnosis
the purpose of nursing diagnosis
to identify the client’s health problems and determine the focus of nursing interventions
is a standardized classification system used to categorize and prioritize nursing diagnoses. It provides a framework for nurses to identify and classify client health problems using a standardized set of diagnostic labels and definitions. NANDA Taxonomy II is widely used in healthcare settings and provides a common language for nurses to communicate about client health problems.
NANDA TAXONOMY
is the process of identifying the client’s health problems and developing a clear and concise statement of the problem. This involves:
Identifying the problem: Accurately identifying the client’s health problem and determining its severity.
Developing a clear and concise statement: Developing a clear and concise statement of the problem that accurately reflects the client’s health status.
nursing diagnosis
Developing an initial plan based on the assessment and nursing diagnosis.
initial planning
Continuously revising and refining the plan as
new information becomes available.
ongoing planning
Developing a plan for the client’s discharge
from the healthcare setting
discharge planning
Interventions that can be performed by
the nurse independently, such as providing education and support.
independent interventions
Interventions that require collaboration
with other healthcare professionals, such as medication
administration.
dependent interventions
Interventions that require
collaboration with the client and other healthcare professionals, such as wound care.
interdependent interventions
Evaluating the plan at specific intervals, such as during a patient’s hospital stay.
planned evaluation
Continuously monitoring and assessing the
client’s progress throughout the healthcare process.
ongoing evaluation
Evaluating the plan to determine its
effectiveness in achieving the desired outcomes.
purposeful evaluation
is the process of recording and maintaining accurate and detailed information about a client’s health status, care, and treatment. It is a critical component of the nursing process, as it provides a comprehensive and accurate record of the client’s care.
documentation
the purpose of documentation is
to provide a comprehensive record, support decision making, improve comm
what is used in documentation
SOAPIE
SCENARIO: A client is admitted to the hospital with a diagnosis of pneumonia. The nurse documents the client’s care using the SOAPIE framework:
Subjective Information: The client reports a history of chronic obstructive pulmonary disease (COPD) and has been experiencing shortness of breath for several days.
Objective Information: The client’s vital signs are: temperature 38.5°C, pulse 120 beats per minute, and blood pressure 140/90 mmHg. The client’s lung sounds are wheezy, and the client has a cough.
Assessment: The client has a diagnosis of pneumonia and is at risk for respiratory failure.
Plan: The client will receive antibiotics and oxygen therapy to manage the infection.
Implement: The client will receive antibiotics and oxygen therapy as ordered.
Evaluate: The client’s vital signs will be monitored regularly to assess the effectiveness of the treatment plan.
SAMPLE OF DOCUMENTATION IN SOAPIE
what is FDAR
focus, data, action, response
What is EHR
electronic health record
A system for organizing and documenting patient data based on the client’s health problems, rather than the date of service.
problem oriented medical record (POMR)
An electronic system for storing and managing patient data, including medical history, test results, and treatment plans.
Electronic health record (EHR)
is the process of communicating information about a client’s health status, care, and treatment to other healthcare providers, caregivers, or family members. It is a critical component of the nursing process, as it ensures that all stakeholders are informed and involved in the client’s care.
reporting
To communicate accurate and timely
information about the client’s health status, care, and treatment to
other healthcare providers, caregivers, or family members.
communicate information
To ensure continuity of care by providing a
clear and concise report of the client’s health status and care.
ensure continuity of care
To support decision-making by providing a
comprehensive and accurate report of the client’s health status and care.
support decision making
isbarr meaning
situation, backround, assessment, recommendations, read back
A report provided by the nurse at the end of their shift to the nurse taking over the client’s care, summarizing the client’s health status, care, and treatment.
change of shift report
is a document used to record and document incidents or adverse events that occur during the provision of healthcare services. It is a critical tool for identifying and addressing potential safety issues, improving patient safety, and reducing the risk of future incidents.
incident report
the purpose of an incident report
document the incidents,
A report documenting a medication error, such as a wrong dose, wrong medication, or wrong route of administration.
medication error report
A report documenting a fall or near-fall incident, including the cause, severity, and any injuries sustained.
fall report
A report documenting an infection control incident, such as a patient contracting an infection or a healthcare worker being exposed to an infectious agent.
infection control report
A report documenting any incident that poses a risk to patient safety, such as a medication error, fall, or equipment failure.
patient safety incident report
is a crucial component of healthcare systems, ensuring that patients receive the necessary care and services from the appropriate healthcare providers.
referral system
is a set of activities undertaken by healthcare providers in response to their inability to provide diagnostic and therapeutic interventions. It involves a two-way relationship between health facilities, ensuring continuity and complementation of health services.
referral system
Referrals made by individuals themselves to higher centers (hospitals) by-passing lower-level facilities based on perceived inadequacy at the lower level.
self-referral
This system ensures that services needed are delivered at the lower level, with competent personnel assigned and roles clearly defined to avoid duplication.
functional referral system
Referrals from lower to higher levels or vice versa, ensuring that patients receive the necessary care and services
external vertical referral
refer to electronic systems designed to store and manage patient data, facilitating the efficient and secure collection, analysis, and sharing of healthcare information. These databases play a crucial role in modern healthcare, enabling healthcare providers to make informed decisions, improve patient outcomes, and enhance the overall quality of care.
health care electronic databases
_____ store information related to patient claims, including billing and insurance data.
claims databases
store medical images, such as X-rays, MRIs, and CT scans, facilitating timely access to imaging studies and aiding in diagnosis.
imaging databases
store genetic information from individuals, populations, and various organisms, contributing to advancing personalized medicine.
genomic databases
centralize information on ongoing and completed clinical trials, facilitating transparency and patient access to experimental treatments.
clinical trial databases
centralize information on ongoing and completed clinical trials, facilitating transparency and patient access to experimental treatments.
clinical trial databases
