Nursing Process - 2 Flashcards
➤ Nursing models or framework
Gordon’s functional health pattern
Orem’s self-care model
Roy’s adaptation model
Wellness model
➤ Nonnursing models
Body system model
Maslow’s Hierarchy of Needs
Developmental theories
is the act of “double checking “or verifying the data to confirm that it is accurate and factual.
Validation
Subjective or objective data observed by the nurse; is what the client says, or what the nurse can see, hear, feel, smell, or measure.
Cues
The nurse’s interpretation or conclusion is based on the cues.
Example: Red swollen wound with drains = infected wound; Dry skin = dehydrated
Inferences
- Documenting data
A ___ is a permanent written communication that documents information relevant to a client’s health care management.
record
takes place when two or more people share information about client care, either face-to-face or by telephone
REPORTING
Purposes or importance of records
Communication
Legal documentation
Nursing audit
Educational( records are useful for educational purposes in various ways e.g. a client diagnosis, s/s of disease, successful and unsuccessful diagnostic findings, and client behaviors)
A factual record contains descriptive, objective information about what a nurse sees, hears, feels, and smells.
The client’s BP is 80/50 mmHg, and the client’s diaphoretic, restlessness and HR are 102 and regular.*(the use of inferences client appears to be in shock)
Factual
The use of exact measurements establishes accuracy.
Use of institution-accepted abbreviations, symbols, and systems of measures.
Accurate
The information will not be completed without full information.
The information within a record entry or a report needs to be complete and contain appropriate and vital information otherwise it’s considered incomplete.
Completeness
To increase accuracy, quality of care and decrease unnecessary duplication, and prevent errors it’s essential to record timely.
For e.g a client’s BP is 140/90 when you’re admitted to some type of drug the nurse should record the same.
Current
As a nurse, you want to communicate information in a logical order.
For example, an organized note describes the client’s knowledge deficit, nurses’ assessment and interventions, and the client’s response.
The nurse should apply theories, critical thinking, EBP, and the nursing process to give logic and order to nursing documentation
Organized
the nurse records all data collected about the client’s health status
data are recorded factually not as interpreted by the nurse
Record subjective data in the client’s words; restating in other words what the client says might change its original meaning
Communicate/Record/Document Data
This was initially defined by Lawrence Weed, MD, is the official method of record keeping used by most medical centers across the world and thus in most (if not all) undergraduate medical schools
Problem-oriented medical record (POMR)
The ___ note originates from the POMR
SOAP
SOAP is an acronym for
Subjective, Objective, Assessment, and Plan
Methods of recording and documentation
Narrative Charting
Traditional client record
___ is a method of recording the patient’s progress under the headings of problem, intervention, and evaluation. When the PIE method is used, assessments are documented on separate forms and the patient’s problems are given a corresponding number
PIE Charting
P-
I -
E -
problem identification
interventions
evaluation
Otherwise known as FDAR charting, it is a method for organizing health information in the individual’s record. It is a systematic approach to documentation, using nursing terminology to describe an individual’s health status and nursing action.
Focus Charting
An ___ chart is a common tool nurses may use to track patients’ health information. Nurses can monitor patient data and evaluate their treatment progress in an organized way.
F-DAR
F-DAR stands for
Focus, Data, Action and Response.
- : is the issue that the nurse addresses when visiting the patient. This can be a diagnosis, pain monitoring, or health lesson.
Focus
- : is the information about the patient’s current status. This can include the patient’s vital signs or a noticeable change in the patient’s condition or behavior.
Data
- : This is the action the nurse takes in response to the data. For
example, the nurse might replace a bandage if they noticed it needed to be changed.
Action
- : This is the response that the patient shows after receiving any treatment. For example, this might include a change in the patient’s vital signs after receiving medication.
Response
The nurse documents only deviations from pre-established norms (document only abnormal or significant findings).
- Avoids lengthy, repetitive notes.
Charting by Exception (CBE)
Components of Charting by Exception:
1) Database: history & assessment data
2) Care Plan: to communicate required care beyond one shift
3) Flow sheets: graphic record, assessments
4) Narrative Notes: Focus on the exception (the complaint), Progress Notes;
5) Profile of care: Kardex;
6) Protocols & Standards: expected assessment data, interventions, and responses.
Nurses use computers to store the client’s database, add new data, create and revise care plans, and document client progress.
Computerized Documentation
CORRECTING ERRORS
IF YOU SPILL SOMETHING ON THE CHART, DO NOT DISCARD NOTES. RECOPY, AND PUT ORIGINAL AND COPIED SHEETS IN THE CHART. WRITE “COPIED” ON COPY.
DO NOT SCRIBBLE OUT CHARTING.
FOLLOW YOUR FACILITIES POLICY.
DO NOT ALTER CHARTING, IT IS A LEGAL DOCUMENT.
*Correct errors by drawing a single horizontal line through the error
*Write the word error above the line, then sign *your signature
*No ink eradication, erasures, or use of occlusive materials.
NANDA definition of a nursing diagnosis is:
“a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”
is a professional assessment of how a person, family, group, or community responds to health issues or life events, or how vulnerable they are to such responses.
Example: Ineffective Airway Clearance related to thick, tenacious secretions and decreased lung expansion secondary to pneumonia.
Diagnosing
Types of Nursing Diagnoses
- An actual diagnosis
2. A health promotion diagnosis - A risk nursing diagnosis
4. Syndrome diagnosis
is a client problem that is present at the time of the nursing assessment.
Ineffective breathing pattern
Anxiety
Body image disturbance
Hypothermia
Fluid volume excess
- An actual diagnosis
relates to clients’ preparedness to improve their health condition.
- Readiness for Enhanced Self-Esteem.
- Readiness for enhanced spiritual well-being
- Readiness for enhanced family coping.
- A health promotion diagnosis
is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem may develop if adequate care is not given.
Risk for Injury
Risk for Infection
Risk for Aspiration
- A risk nursing diagnosis
clinical judgment concerning a specific cluster of nursing diagnoses
that occur together and are best addressed together and through similar interventions.
Example: Post-trauma syndrome
A diagnosis that includes as several defining characteristics including Anxiety, Fear, Grieving, and Hopelessness
- Syndrome diagnosis
Components of a NANDA Nursing Diagnosis
- Problem (P):
- Etiology (E):
- Signs and symptoms (S):
Components of a NANDA Nursing Diagnosis
statement of the client’s health problem (NANDA label)
Severe right iliac pain
- Problem (P):
causes of health problems
related to inflammation of the appendix
- Etiology (E):
defining characteristics manifested by the client.
as evidenced by increased WBC, fever, and C-shaped position.
- Signs and symptoms (S):
Nursing Diagnosis- Medical diagnosis
Ineffective breathing pattern - Asthma
Activity intolerance - Cerebrovascular accident
Acute pain- Appendicitis
Disturbed body image- Amputation
Ranking of nursing diagnoses in order of importance
PRIORITIZING NURSING DIAGNOSES
___ priority - if untreated could harm to client Ineffective breathing pattern
High
___ priority - non-life-threatening
Risk for impaired skin integrity
Fatigue
Medium
___ priority - not directly related to current illness or prognosis Impaired social interaction
Low
It is the process of formulating client goals and designing the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.
OUTCOME IDENTIFICATION AND PLANNING
refers to formulating and documenting measurable, realistic, and client-focused goals that will provide the basis for evaluating nursing diagnosis.
Outcome Identification
TYPES OF PLANNING
Initial planning
Ongoing planning
Discharge planning
TYPES OF PLANNING
the nurse who performs the admission usually develops the this type of comprehensive plan of care.
Planning is done after the initial assessment.
Initial planning
Is done by all nurses who work with the client.
It is a continuous planning.
Ongoing planning
The process of anticipating and planning for needs after discharge.
Planning for needs after discharge
Discharge planning
- Setting priorities
- ___ is the process of establishing a preferential sequence for addressing nursing diagnoses and interventions
- High priority
- Medium priority
- Low priority
Priority setting
Nurses frequently use Maslow’s hierarchy of needs when setting priorities
Planning process:
Setting priorities
Establishing client goals/desired outcomes
Selecting nursing interventions and activities
Writing individualized nursing interventions on care plans.
