Nursing Process Flashcards
1
Q
Dimensions of Health and Well-Being
A
Physical
Social
Mental
2
Q
Disease
A
objective state of health, the pathological process of which can be detected by medical science.
3
Q
Illness
A
subjective experience of loss of health
4
Q
Dimensions of Health and Well-Being - Mental
A
Meaning, Purpose
Ability to do things one enjoys
5
Q
Dimensions of Health and Well-Being - Physical
A
Vitality, Energy
Ability to do things one enjoys
Enjoyment of good social relations
Feeling of control over life, living conditions
6
Q
Dimensions of Health and Well-Being - Social
A
Connectedness, “Community”
7
Q
Clearly depicts the concept of holism, whereby health is more than the sum of the component parts in that the interrelationships between and among different components result in different aspects of health
A
8
Q
Social Determinants of Health
A
Economic and social conditions that shape the health of individuals,
communities and jurisdictions as a whole and determine the extent to which a person possesses the physical, social and personal resources to identify and achieve personal aspirations, satisfy needs and cope with the environment
9
Q
Social Determinants of Health
A
Income and Income Support
Education
Unemployment and Job Security
Employment and Working Conditions
Early Childhood Development
Food Insecurity
Environment
Housing
Social Exclusion
10
Q
Rural populations may experience more increased risks for injuries and decreased cardiovascular disease
A
11
Q
3 major approaches to health
A
Medical
Behavioural
Socioenvironmental approach
12
Q
Medical Approach
A
Represents a stability orientation to health, dominated Western thinking for most of the 12th century.
Emphasizes the notion that medical intervention restores health.
Health problems are defined by physiological risk factors (hypertension, obesity)
13
Q
Behavioral Approach
A
Focus primarily on health practices
Behavioral approach was challenged by new studies.
14
Q
Socioenvironmental Approach
A
nurses would use this approach when caring for a family.)
Emphasizes psychosocial factors and socioenvironmental conditions
Poverty, unhealthy physical and social environments (air pollution, etc.)
Social determinants of health would be income and social status
Health and promotion and prevention strategies are focused on policy interventions that benefit the whole population
15
Q
Health Promotion and Disease Prevention
A
Primary Prevention
Secondary Prevention
Teritary Prevention
16
Q
Primary Prevention
A
protect against disease before signs and symptoms occur. Example would be immunizations and reduction of risk factors (smoking, inactivity)
17
Q
Secondary Prevention
A
Early detection of disease
18
Q
Tertiary Prevention
A
activities directed toward minimizing disability from disease and helping clients learn to live productively with their limitations)
19
Q
Health Promotion
A
Integrates concepts of population health with health promotion
Aims to develop actions that improve health
Answers 4 questions: who, what, how and why
20
Q
Documentation
A
Nurses observe a patient’s behaviour, ask questions about the natures of the problem, listen to the cues that the patient provides, and conduct a physical examination for further information.
Nurses understand that “coordination of patient care in collaboration with individuals’ families and other members of the health care team” is completed in all phases of the nursing process.
21
Q
The Nursing Process
A
Primary Source
Secondary Source
Tertiary Source
22
Q
Primary Source
A
The patient themselves
23
Q
Secondary Source
A
patient medical records, caregivers,
24
Q
Tertiary Source
A
nurses complete the assessment by reviewing nursing , medical and pharmacological literature about a patient’s present health status.
Nurses Experience
25
ADPIE
A – Assessment
D – Diagnosis
P – Plan
I – Implementation
E – Evaluation
26
Assessment
A nurse makes a quick observational overview or screening or a cue (patient is crying is a cue that can imply fear or sadness)
Nurse then categories cues, making inferences and identify emerging patterns, potential problem areas and solutions.
Collect
Subjective – verbal descriptions of their health concerns (patient is nauseous)
Objective – observations and measurement of patient’s health status (i.e. temperature)
Each source of data provides information about the patient's level of wellness, strengths, prognosis risk factors, health practices and goals, etc
Primary Source – the patient themselves
Secondary Source – patient medical records, caregivers,
Tertiary Source – nurses complete the assessment by reviewing nursing , medical and pharmacological literature about a patient’s present health status.
Think about what to assess and their health history
27
Data Collection
Interview – collect objective data
Introduce themselves to patient
Establish caring relationship with the patient
Obtain insight of patients concerns
Data
Closed-ended questions “Do you feel the medication is helping you?”
Termination Phase
Nurse provides clues that interview is coming to an end. “I want to ask just two more questions…”
28
Concept Mapping
Knowledge
Standards
Qualities
Experience
29
Diagnosis
Nursing Diagnosis
Determine Nursing Care
Nursing Diagnosis – health issue
Clinical Judgement about individual, family or community response to actual and potential health problems or life processes
Helps facilitate understanding of patient problems among healthcare providers
Medical Diagnosis
Identification of a disease / condition
Not in the scope of the PN
30
Example of Medical Diagnosis vs Nursing Diagnosis
Medical Diagnosis: Mycardial Infarction
Nursing Diagnosis: fear, pain, altered tissue perfusion, etc.
Standard nursing diagnostic statements : provide common language for all healthcare to understand, enables nurses to communicate their actions among themselves to other healthcare providers. Help nurses focus on the scope of nursing practice and develop nursing knowledge.
31
Formulation of the Nursing Diagnosis
Actual Nursing Diagnosis
Responses to health conditions or life processes that exist in an individual, family or community
Risk Nursing Diagnosis
Develop in a vulnerable individual, family – physiological, psychosocial, family – increase patient’s vulnerability
Health Promotion Nursing Diagnosis
Increase wellbeing and human health potential (exercise, etc.)
Wellness Nursing Diagnosis
Patient wishes or has achieved optimal health
32
Provide and execute the interventions that are definitive for prevention, treatment or promotion
Nursing diagnosis is written in a two-part format: a diagnostic label and an etiological or related factor
Nursing diagnosis – clinical judgement about individual, family or community responses to actual and potential health problems or life processes
33
Planning
SMART Goals
Specific, measurable, achievable, relevant and timely
Person-centered, singular and mutually agreed upon
Measured using expected outcomes
Requires critical thinking applied through deliberate decision making and problem solving.
Priority setting is ranking nursing diagnoses or patient problem using principles such as urgency or importance.
High priority are sometimes both physiological and psychological and may address other basic human needs.
Intermediate priority nursing diagnoses involve the nonemergency, non life threatening needs of the patient
Low priority items – are not always directly related to a specific illness or prognosis but affect the patent's future well being
34
Nurses are responsible for developing a written plan of care for patients.This includes nursing diagnosis, goals, expected outcomes, or both.
35
Implement
Initiates interventions that are most likely to achieve the goals expected and outcomes needed to support or improve patient’s health status
36
Direct Care
performed through interactions
37
Indirect Care
– interventions performed away from patient
38
Correctly stated nursing inverventions
Turn patient every 2 hours, using the following schedule:
0800: supine
1000: left side
1200: prone
Replace patient’s dressing with Neosportin ointment to wound and two dry 4x4 dressings secured with hypoallergenic tape, once a shift: 0800, 1600 and 2400
39
Independent nursing interventions are actions that do not require director or orders from other healthcare providers.
Dependent nursing interventions are actions that do require orders or directions from physicians
40
Interventions are not selected at random. When choosing interventions, the nurse considers six factors:
The nursing diagnosis
Goals and expected outcomes
The evidence base (research or proven practice guideline)
Feasibility
Acceptability to the patient
The nurse's competence
41
Assessment is a continuous process that occurs each time the nurse interacts with the patient. As new data is collected and patient needs change or resolve, nurses modify the plan of care.
Revise data in the assessment, date any new data
Revise the nursing diagnoses and delete those that are no longer relevant
Revise specific interventions that correspond to the new nursing diagnoses and goals
Determine the method of evaluation for any outcomes achieved
42
Nursing practices includes cognitive, interpersonal and technical skills to implement direct and indirect nursing care.
43
Cognitive Skills
make good judgement and sound clinical decisions
44
Interpersonal Skills
develop a trusting relationship and express a caring attitude
45
Psychomotor Skills
integration of cognitive and motor activities. For example, giving an injection, nurses need to understand anatomy, physiology and pharmacology to the injection is done correctly.
46
Direct Care
Nurses need to always be sensitive to a patient’s clinical condition, values and beliefs, expectations and cultural views.
47
Direct Care
Instrumental Activities of Daily Living
Instrumental activities of daily living include shopping, preparing meals, writing cheques, and taking medication.
Nurses in home care and community health care do these.
Physical Care Techniques
Turning, positioning, changing dressings, administering medication
Controlling for Adverse Reactions
Harmful effect on medication, diagnostic test,
Nurses are expected to know potential adverse reactions associated with nursing interventions.
Nurse checks every 5 minutes for any adverse reaction (redness) when using a heating compress, etc.
Life-saving measures
48
Indirect Care
Communicating Nursing Interventions
Communicated in writing, verbally or both.
Interventions are part of both the nursing care plan and the medical record.
After completing nursing interventions, the nurse documents the treatment and patients response in appropriate record
Delegating, Supervising and Evaluating the Work of Other Staff members
49
Examples of Indirect Care
Documentation
Delegation of care activities
Medical order transcription
Infection control (proper handling and storage of supplies
Environmental safety management
Computer data entry
Change of shift report
Collecting, labelling and transporting lab specimans
Transporting patients to other units
50
Evaluation
Final step in nursing process.
Involves two components
An examination of a condition or situation
Judgement as to whether change has occurred.
51
Evaluation is an ongoing process whenever a nurse has a contact with a patient. Collaboration is a key component of the evaluation process and is found to be an overarching theme in person-centred care
52
E - Evaluation
Identifying Criteria and Standards
Goals – expected behaviour or response that indicated resolution of a nursing diagnosis or maintenance of a healthy state. It is a summary statement of what will be accomplished when the patient has met all expected outcomes.
Considers two factors; the appropriateness of the interventions selected and the correct application of the intervention
A standard of care is the minimum level of care acceptable to ensure a high quality of care.
A nurse reviews the standard of care to determine whether the right interventions have been chosen or whether additional ones are required.
Expected Outcomes
Outcomes refer to the changes that have occurred in response to nursing care.
Examples of nursing sensitive outcomes are reductions in pain severity, incidents of pressure injuries
Outcomes are statements of progressive step by step responses or behaviours that must be achieved in order to accomplish the goals of care. An outcome defines the effectiveness, efficiency and measurement of the results of nursing interventions.
NOC (nursing outcome classifications) are designed to provide the language for the evaluation step of the nursing process
Purpose is to: identify, label, validate and classify nursing sensitive patient outcomes, field test and validate the classification and define and test measurement procedures for the outcomes and indictors using clinical data
53
Summarizing Findings
Examine the outcome criteria to identify the exact desired patient behaviour or response
Assess the patient’s actual behaviour or response
Compare the established outcome with actual behaviour or response
Judge the degree of agreement between outcome criteria and the actual behaviour of response
If the outcome criteria are not in agreement what are the barriers to agreement
54
Four Types of Documentation:
Narrative
SOAP
PIE (Problem Intervention-Evaluation Note
DAR (Data-Action-Response)
55
Legal requirement on documentation is no space after entry and nurses signatures. Time and date is also important.
For errors: draw a single line through error. Write “error” above it and sign your name or initials and date it.
Abbreviations: units of measurement should be where abbreviations should be used.
If it wasn’t documented, it didn’t happen
56
SOAP
S – Subjective (verbal)
O – Objective (measured and observed)
A – Assessment (diagnosis based on data)
P – Plan (what caregiver plans to do)
57
Subjective
Patient’s own words / family history / medications, describe onset / location / frequency / intensity / duration / allergies
58
Objective
Includes vitals, test lab results / facial expressions and body language (i.e. blood pressure, pulse, weight, lab results, temperature)
59
Assessment
Diagnosis drawn from observation, statements of risk the patient has, reasoning for plan
60
Plan
Include all intentions, meds and treatments, therapies / education and referrals.
61
Health Documentation should be:
Factual
what a nurse sees, hears, feels, smells
Accurate
Data should be charted and accurate
Complete
Contain essential information
Concise
Needs to be clear, to the point and easy to understand
Current
Vital signs, pain assessment, change in patient’s status, admission, etc.
Organized
62
Types of Documentation
Narrative Documentation
Story-like format to document specific information about a patient’s condition and nursing care. – presented in chronological order
Problem-Oriented Medical Records
Structured method of narratives that emphasizes a patient’s problems. Organizes data using nursing process. Data is organized by problem or diagnosis
Database / Problem List / Care Plan / Progress Notes
SOAP
Focus Charting (DAR) Data –Action-Response) Note
63
Miliary time is used.
Do not use abbreviations
EHR – electronic health record – digital version of patient data (lifetime record of all health care encounters for a patient.
EMR – electronic medical record
Source Record – patient’s chart so each discipline has a separate section in which to record data.
64
Traditional Source Records
Admission Sheet
Order Sheet
Nurses Admission Assessment
Graphic Sheet and flow sheet
Medical history and examination
MAR (medications administered to patient, date, time, dose, route, etc.
Progress Notes - ongoing record of patient's progress and response to therapy completed by all members of health care team
Healthcare disciple's record
Discharge summary
65
Health Promotions Strategies
Build Health Public Policy
Create Supportive Environments
Strengthen Community Action
Develop Personal Skills
Reorient Health Services
66
Build Health Public Policy
This strategy is the foundation of all other because policies shape how money, power and material resources are distributed to society.
Extends beyond traditional health agencies as government health departments to other sectors (education, transportation, labour, energy, etc.)
67
Create Supportive Environments
Comprehensive School Health Initiative – focuses on improving school environments by providing health instruction, social support, positive physical environments
68
Strengthen Community Action
(Community Development) – effective community action in setting priorities, making decisions and planning and implementing strategies
69
Develop Personal Skills
Most familiar to nurses, helps clients develop personal skills, enhance coping strategies, gain control over their health and environments so they can make healthy lifestyle choices.
70
Reorient Health Services
Shift the emphasis from treating disease to improving health and make the health care system more efficient and effective.
71
Purpose of Medical Records / Documentation
Communication and Care Planning
Legal Documentation
Funding and Resource Management
Education
Research
Auditing and Monitoring
72
NANDA-I
North American Nursing Diagnosis Association International
Standardized Terminology
Global force for development and use of nursing standardized terminology to ensure patient safety
73
Documentation things to remember:
Record all facts
Document as close as possible of time of event
Document only for yourself
Avoid generalization.
Begin each entry with date and time
Do not prechart
Protect the security of your password for computer
documentation
Each member of health care team need to be:
Accurate
Timely
Concise
Organized
Comprehensive plan of care
Information about the patient’s healthcare is recorded after each contact with the patient
74
Guidelines
Do not erase, white out or scratch out errors
Draw a single line through and write “error” above it. Sign your name or initials and date it
Do not leave blank spaces or lines in a written nurses progress notes
Record all entries legibly and in black ink.
