Nursing Process, Nursing Diagnosis, and MRM Flashcards
What is the nursing process?
A - assess
D- diagnose
P - plan
I - implement
E - evaluate
Clinical reasoning
cognitive process that uses formal and informal thinking strategies to analyze client information, evaluate the significance, and consider alternate actions
Used in determining a diagnosis
What is the three part nursing diagnosis?
P - problem (nursing diagnosis label from NANDA-I)
E - etiology (related to phrase contributing to the problem- pathophysiology)
S - symptoms (defining characteristics/symptoms)
What is a problem-focused diagnosis?
a clincial judgement converning an undesirable human response to a helath condition or life process
Risk nursing diagnosis
clinical judgment concerning the susceptability to developing an undesirable response to a condition
Example: Pt states they feel unbalanced and are afraid of falling down the stairs, but have not falled before
Health promotion nursing diagnosis
clinical judgment concerning motivation to increase well being
Steps to making a nursing diagnosis
- determine relevant symptoms
- make a list of symptoms
- clluster similar symptoms
- analyze/interpret the symptoms
- Select nursing diagnosis form NANDA-I list
Symptom pattern recognition
process of identifying symptoms that patients have related to their illness, understanding which require intervention, and identifying the associated time-frame to intervene
How should you determine priority nursing diagnosis?
Patient priority and mutual goals
Safety: ABCs and Maslows
What are the QSEN competencies?
- Patient-centered care
- Teamwork
- Evidence-based practice
- quality improvement
- safety
- informatics
Primary, secondary, and tertiary sources of information
Primary: patient
Secondary: nurse and family
Tertiary: medica lam and chart
What are the 4 major categories of data per MRM?
- description of the situation
- expectations
- resource potential
- goals and life tasks
What are the 3 parts of the description of the situation per MRM?
Overview of the situation
Etiology (stressors and distressors)
Therapeutic needs
What is the purpose collecting data on expectations?
To develop an undertsanding of the client’s personal orientation in term of their expectations for the present and future.
*can they project themselves into the future? Useful for goal setting
What is included in expectations?
Immediate
Long term
What are the parts of resource potential?
- External: Social network, Support system, Health care system
- Internal: Strengths, Adaptive potential (Feeling states; Pshyiological data)
What is included in goals and life tasks?
- current
- future
What is the purpose of collecting data on goals and life tasks?
To determine current developmental status to understand the client’s personal model
The 5 aims of nursing interventions
- Build trust
- Promote client’s positive orientation
- Promote client’s control
- Affirm and promote client’s strengths
- Set mutual goals that are health directed
What is a nursing diagnosis?
- Prioritizing hypotheses
- Clinical judgment concerning human response to health condition or life processes
What should be considered when creating a nursing diagnosis statement?
- Defining characteristics and related factors should be specific to the patient’s situation
- Diagnosis should be from the approved NANDA-I list
What is an outcome?
A measurable change in the client’s status
What is an intervention?
Things the NURSE does to facilitate achieving the outcome
What is the MRM theory of nursing interventions?
- Humans are individualistic since they model their world uniquely
- Interventions should be planned in the guidelines of similiarites between people
- Similarities are reflected in the 5 major principles (MRM Aims of Intervention)
What is the principle behind building positive orientation as a nursing intervention aim?
Affiliated-individuation is dependent on the individual’s perceiving that they are an acceptable, respectable ,and worthwhile human.
What is the principle behind promoting client control?
Human development is dependent on the person’s perceiivng that they have control over their life, while also sensing affiliation (dependence is not a bad thing)
What is the principle behind affirming a client’s strengths?
There is an innate drive toward holistic health that is facilitated by consistent nurturance
What is the principle behind setting mutual goals that are health directed?
Human growth is dependent on satisfaction of basic needs and facilitated by growth-need satisfaction
Independent nursing interventions
- actions the nurse can initiate without a providers order
Collaborative nursing actions
- Actions that require an order from the provider
- Could be recommended by the nurse within SBAR
What factors should be included in selecting an intervention?
- Characteristics of the problem (hypothesis)
- Goals and outcomes
- Client preference/ability
- Evidence for interventions
- Feasibility of intervention
- Nurses’ competence
