Identifying Clinical Problems in Nursing Practice 1 Flashcards
What is nursing practice?
Problem solving approach to gather information/scientific data
The primary purpose of the nursing process?
to assist nurses to manage patient care in a scientific and creative manner
Based on the scientific problem solving method
Steps of nursing process?
- assessment and diagnoses
- planning
- implementation
- evaluation
assessment and diagnoses phase?
Collecting and analyzing assessment data in order to identify self-care deficits (nursing diagnoses)
planning phase?
Designing plan of care that is tailored to the patient’s problems:
How to prevent, reduce, resolve problems
how to implement nursing interventions
How to support patient’s self care abilities
implementation phase?
Carrying out planned nursing interventions
evaluation phase?
Judgement of the effectiveness of nursing care to meet patient goals:
Were the goals achieved?
Essential Elements of the Nursing Process?
Problem-oriented Dynamic patient-centered Goal-directed planned creative cyclic
purpose of data collection?
identify areas in which nursing intervention is required
directed to specific problems or needs
Types of Data Collected?
subjective data
objective data
self-care practices (SCP) data
lab/chart data
Techniques Used to Collect Data?
Interview
Physical Examination Techniques:
inspection-observe/look/smell
palpation-touch
percussion-tapping with hands
auscultation-listen with stethoscope
objective Data?
information about a person that can be perceived, measured or observed by another person.
Examples of objective data, temp., weight, appearance
subjective data?
info is reported by patient
Examples: pain, fatigue
SCP Data?
Information pertaining to the practices the patient would normally carryout in order to meet his/her self-care requisites.
lab/chart Data?
Information from the patient’s chart including:
Blood work results
Results of diagnostic tests
Consults/note from other members of the health care team.
Information from progress notes.
Basic Conditioning Factors (BCF)?
age sex pattern’s of living sociocultural orientation developmental state health state family system factors health care system factors
Part of collecting your data base
Making Inferences?
Your ability to identify cues and make inferences is influenced by:
your observational/assessment skills
your nursing knowledge
your nursing expertise
What is inference?
How you interpret or perceive a cue – the conclusion you draw about the cue – is called an inference.
ASSUMPTION
Validating Data?
ensure that assessment information is complete, accurate and factual
Eliminate any errors you may have
identify missing key information
When to validate data?
when data conflicts
patient seems odd/unusual
Clustering Data?
Organizing your data using the tools from orem’s model helps you to cluster your data
No tools do all of the clustering you need to do to understand and identify every problem.
You need to think about the relationships among the pieces of data and among the self-care requisites
Action Demand?
Analyze all of the information and draw a conclusion regarding the situation.
This involves the generation of an action demand related to the self-care requisite of concern.
Consists of these two components:
1) action demand statement (ADS) (synthesis statement)
2) actions to be taken
How to write the ADS?
verb + USCR + in a + age + sex of the patient + story that makes it particular
Action demand; actions to be taken
Actions to be taken:
What needs to be done to meet the goal described in the synthesis statement.
Should be based on sound scientific rationale
Example –Action Demand
Action Demand Statement :
Decrease risk of injury in a 72 year old gentleman who is blind and experiences orthostatic hypotension.
Actions:
1) changing position slowly
2) changing position in stages
3) drinking 2-2.5 liters/day
Information in patient’s data base?
Health problems and responses to these problems, name, age, sex, place of birth, family support system
Sources of data?
Client
Family/significant other
Health care team
Medical records
Methods for gathering data?
Interview
Physical examination
Techniques used when performing physical examination?
Inspection/smell Palpation Percussion Auscultation Vital signs Height Weight
What is data validation?
Compare data with another source of data to determine accuracy
Data organization involves?
Organizing data according to patterns and cues
Data clustering involves?
Set of signs and symptoms grouped together in a logical way
