Nursing diagnosis Flashcards
1
Q
meyer’s law
A
- nurses are paid for how they think
2
Q
critical thinking in nursing
A
- also called clinical judgments
- Aims to make judgments based on evidence rather than conjecture
- Based on principles of science & scientific method
- Goal is to make decisions that enhance patient safety &
wellbeing - Process used is called the Nursing Process
- observe and notice things abt the patient
- help pt adapt from one level to another –> bring towards health
3
Q
definition of nursing
A
- Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations (ANA, p. 2015)
4
Q
definition of process
A
- Progressive course, moving forward from one point to
another using a detailed methodology (Webster) - Purpose, Organization, Creativity
- 5 Steps: assessment, diagnosis, planning, implementation, evaluation
- help treat human response
5
Q
nursing process: historical overview
A
- lydia hall coined term “nursing process”
- faculty at catholic university of america spelled out a 4 step process
- 1973: gebbie and lavin @ slu called first national conference on classification of nursing diagnosis
- ANA standards of nursing practice included 5 step process
6
Q
assessment
A
- the RN collects comprehensive data pertinent to the patient’s health or the situation
7
Q
diagnosis
A
- the RN analyzes the assessment data in determining diagnoses or issues
8
Q
outcome identification
A
- the RN identifies expected outcomes for a plan individualized to the patient or the situation
- Ex: if pt isn’t breathing good, my goal or outcome identification = no longer have pt have S.O.B
9
Q
planning
A
- the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes
10
Q
implementation
A
- the RN implements the identified plan
11
Q
evaluation
A
- the RN evaluates progress toward attainment of outcomes
- look back @ outcome identification
12
Q
framework at SLU: adaptation
A
- Humans are biopsychosocial, spiritual beings
- Adaptation may involve one, several or all dimensions of patient behavior
- Adaptation is an attempt to maintain optimal integrity
- Knowledge of adaptation–> definition of adaptive patterns
13
Q
assessment definition
A
- Systematic method of data collection which consists of
the appraisal of the individual, family, community for the purpose of identifying responses to potential or actual health needs - Must include all dimensions of adaptation
- Must be systematic, accessible, communicated &
recorded (ANA) - learning abt pt
- coming up w/ what’s wrong with them
14
Q
assessment: sources of data
A
- patient (primary source)
- significant others, family, friends– secondary source (if pt can’t talk like infant, etc)
- nurse (use our senses to gather info)
- patient’s record (look in history, look at lab work, etc)
- IP team
15
Q
Assessment: The Procedure
A
- Nursing history: ask patient abt past med history, how they are feeling, what led to them to coming to the hospital
- Subjective data
- Observation
- Objective data: factual, see for ourselves
- Instruments used to enhance
- Measurement: Ex: normal temp btw 98.6 and 99
- Most objective data
16
Q
Analysis of Assessment Data
A
- Data processing
- Organize
- Validating the data
- Verify data
- Identify gaps and inconsistencies
- Compare interview with physical exam (some info might not match to what they are saying)
- Clarify ambiguous statements
- Double check abnormal data
- Any factors that interfered?
- Verify data
17
Q
Which statements require validation?
A
- The patient tells you he is not anxious about the X-ray. He is pacing the room. His
skin is cool & clammy. (YES. we want to make sure it’s actually anxiety) - The patient says he smokes 2 packs of cigarettes a day. You observe his teeth and fingers are brown stained. (NO)
- The patient tells you that she lives alone. In a later conversation she mentions a
“housemate”. (YES) - The mother says her little boy “eats like a horse”. You observe that the child is thin and small for his age. (YES)
- The patient says he is experiencing the worst pain he has ever had. He is lying quietly in bed. You note facial grimacing. (NO)
18
Q
cues
A
- A cue is a piece of information or data that influences decisions
- Cues point to a change in the patient’s health status or pattern
- Cue varies from norms of the patient population
- Cue indicates a developmental delay
19
Q
identifying cues
A
- temp of 101 (not normal)
- pulse rate 150 (adult) (not normal)
- has hives over entire body
20
Q
identifying cues pt. 2
A
- pt c/o pain on urination
- older adult does not recognize fav childhood
- infant cried, pulls at his ears and can’t be consoled by mother
21
Q
cluster data
A
- make inferences
22
Q
possible errors in clustering
A
- premature data interpretation
- ex: pts husband died and says they have no energy. you say they are depressed
- bias/stereotypes
23
Q
hypothesis
A
- Result of grouping of signs & symptoms during clustering
- Signs & symptoms are defining characteristics
- Ask:
- Does an actual or potential health care problem exist?
- What are patient’s strengths?
- Verify with patient
