Nursing Process Flashcards
What are the purposes of the diagnosing step in the Nursing Process?
- Identify how an individual, group, or community responds to actual or potential health and life processes
- Identify factors that contribute to, or cause, health problems (etiologies)
- Identify resources or strengths on which the individual, group, or community can draw to prevent or resolve problems
Patient Problems Statements focuse on what?
Problem statements focus on unhealthy responses to health and illness; may change from day to day as the patient’s responses change
Medical Diagnosis identifies what?
Identifies diseases
Medical Diagnosis describes what?
describe problems for which the physician or advanced practice nurses directs the primary treatment;
Does the medical diagnosis change?
remains the same for as long as the disease is present
Diagnostic Reasoning, Clinical Reasoning, and Clinical Judgment- how to?
Be familiar with lists of actual and potential problems and needs; read professional literature and keep reference guides handy
Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide
Respect your clinical intuition, but before writing a problem statement without evidence, increase the frequency of your observations and continue to search for cues to verify your intuition
Recognize personal biases and keep an open mind
Steps of Data Interpretation and Analysis
Recognizing significant data: Comparing data to standards
Recognizing patterns or clusters
Identifying strengths and current or potential problems
Identifying potential complications
Reaching conclusions
Partnering with the patient and family
Types of Nursing Diagnoses
Problem-focused
Risk
Health promotion
Formulation of Nursing Diagnoses
Problem
Etiology
Signs and Symptoms
What is ‘Problem’ in the Formulation of Nursing Diagnoses?
Identifies what is unhealthy about patients
What is ‘Etiology’ in the Formulation of Nursing Diagnoses?
Identifies factors maintaining the unhealthy state
Goal of Outcome Identification and Planning Step
Establish priorities
Identify and write expected patient outcomes
Select evidence-based nursing interventions
Communicate the nursing plan of care
A Formal Care Plan Allows the Nurse to:
Individualize care that maximizes outcome achievement
Set priorities
Facilitate communication among nursing personnel and colleagues
Promote continuity of high-quality, cost-effective care
Coordinate care
Evaluate patient response to nursing care
Create a record used for evaluation, research, reimbursement, and legal reasons
Promote nurse’s professional development
Outcome Identification, Planning, and Clinical Reasoning #1: What should you be familiar with?
Be familiar with standards and agency policies for setting priorities, identifying and recording expected patient outcomes, selecting evidence-based nursing interventions, and recording the care plan
Outcome Identification, Planning, and Clinical Reasoning #1: What is the goal?
Remember that the goal of thoughtful, patient-centered practice is to keep the patient and the patient’s interests and preferences central in every aspect of planning and outcome identification
Outcome Identification, Planning, and Clinical Reasoning #1: What is the ‘big picture’ focus?
Keep the “big picture” in focus: What are the discharge goals for this patient, and how should this direct each shift’s interventions?
Outcome Identification, Planning, and Clinical Reasoning #2
Trust clinical experience and judgment but be willing to ask for help when the situation demands more than your qualifications and experience can provide; value collaborative practice
Respect your clinical intuitions, but before establishing priorities, identifying outcomes, and selecting nursing interventions, be sure that research supports your plan
Recognize your personal biases and keep an open mind
Three Elements of Comprehensive Planning
- Initial
- Ongoing
- Discharge
Initial Planning- who is it developed by?
Developed by the nurse who performs the nursing history and physical assessment
Initial Planning- what does it address?
Addresses each problem listed in the prioritized problem list
Initial Planning -identifies what?
Identifies appropriate patient goals and related nursing care
Ongoing planning- who is it carried out by?
Carried out by any nurse who interacts with patient
Ongoing planning- what does it do to the plan?
Keeps the plan up to date, manages risk factors, promotes function
Ongoing planning- what does it have to do with problem statements?
States problem statements more clearly
Develops new problem statements
Ongoing planning- what does it do to the outcomes and nursing interventions?
Makes outcomes more realistic and develops new outcomes as needed
Identifies nursing interventions to accomplish patient goals
Discharge Planning- who is it carried out by?
Carried out by the nurse who worked most closely with the patient
Discharge Planning- when does it begin?
Begins when the patient is admitted for treatment
Discharge planning: what does it use?
Uses teaching and counseling skills effectively to ensure that home care behaviors are performed competently
What is the first part of the nursing diagnosis? (problem statement)
Identifies the unhealthy response
Indicates what should change
What does the first part of the nursing diagnosis LEAD to?
Suggests patient goals/outcomes (expectations for change)
What is the second part of the nursing diagnosis? (etiology)
Identifies factors causing or contributing to the undesirable response and preventing desired change.
What is the second part of the nursing diagnosis? (etiology) lead to?
Suggests nursing interventions
What are the priorities that need to be established?
Maslow’s hierarchy of human needs
Patient preference
Anticipation of future problems
Critical thinking/clinical reasoning and judgement
Maslow’s hierarchy of human needs
Physiologic needs
Safety needs
Love and belonging needs
Self-esteem needs
Self-actualization needs
Clinical Reasoning and Establishing Priorities #1
What problems need immediate attention and which ones can wait?
Which problems are the responsibility of the nurse and which need to be referred to someone else?
Which problems can be dealt with by using standard plans (e.g., critical paths, standards of care)?
Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge?
Clinical Reasoning and Establishing Priorities #2
Have changes in the patient’s health status influenced the priority of nursing diagnoses/problems?
Have changes in the way the patient is responding to health and illness or the care plan affected those nursing diagnoses/problems that can be realistically addressed?
Are there relationships among diagnoses/problems that require that one be worked on before another can be resolved?
Can several patient problems be dealt with together?
Categories of Outcomes
Cognitive:
Psychomotor:
Affective:
Categories of Outcomes: Cognitive
describes increases in patient knowledge or intellectual behaviors
Categories of Outcomes: Psychomotor
describes patient’s achievement of new skills
Categories of Outcomes: Affective
describes changes in patient values, beliefs, and attitudes
Clinical outcomes
Clinical outcomes describe the expected status of health issues at certain points in time, after treatment is complete. They address whether the problems are resolved or to what degree they are improved
Functional outcomes
Functional outcomes describe the person’s ability to function in relation to the desired usual activities
