test 2 Flashcards
Steps of nursing process in order
- Assessment
- Diagnosis (nursing)
- Planning
- Implementation
- Evaluation
- Systemic problem-solving process that guides all nursing actions
- Help nurse provide goal-directed, client centered care
Nursing Process
- Systemic gathering of data and ongoing process
- Categorizing data (cluster cues)
- Recording data
Assessment
- Identifying client’s actual or portentously health needs, problems, and strengths
- Pt’s response to their illness
Diagnosis
Data about client’s motivation, family, and available resources help you and the client formulate realistic goals
Planning
Decide goals you want to achieve with your nursing activities, keep pt in mind
Planning outcomes
Assess data to choose interventions to help the client achieve stated goals
Planning interventions
Putting plan into action and making sure pt is able to do it
- gather data by observing the client’s response as interventions are performed
Implementation
Types of nursing knowledge
Theoretical, Practical, Self, and Ethical
- Knowing “why”
- EBP facts/theories from nursing and other disciplines
- Understanding why you need to do something with research to back it up
Theoretical
Knowing “what to do and how to do it”
- basically what we’re doing in the skills lab
Practical
Knowing yourself and your beliefs, understanding your self
- Help decrease bias and errors in planning individual care
Self
Our obligation, knowing right from wrong
- Doing the right thing
Ethical
Assessment focused on disease and pathology; doctor does the orders
- Diseased process related
Medical diagnosis
- Assessment that focus on client’s response to illness
- Considered to be the symptoms, the nurse’s role is to make interventions to alleviate symptoms
Nursing diagnosis
The different types of assessment
Comprehensive, initial focused, and ongoing focused
Global, nursing/patient database, admission
Comprehensive assessment
- Used to follow up on symptoms or findings from first examination
- First time seeing and focusing on it
Initial focused assessment
Evaluate the status of existing problems and goals
Ongoing focused assessment
Maslow’s hierarchy of needs from bottom to top
- Physiological
- Safety
- Love/belonging
- Esteem
- Self-actualization
Breathing, food, water, sex, sleep, homeostasis, excretion
Physiological of Maslow’s Hierarchy
Security of…
body, employment, resources, morality, family, health, and property
Safety of Maslow’s Hierarchy
Friendship, family, and sexual intimacy
Love/belonging of Maslow’s Hierarchy
Self-esteem, confidence, achievement, respect of others, respect BY others
Esteem of Maslow’s Hierarchy
Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
Self-actualization of Maslow’s Hierarchy
Grouping given data
Cluster cues
Goal that needs to be achieved within a few hours or days
- By end of shift, end of day
Short-term
Goal that needs to be achieved over a longer period of time (week, month, or more)
- by discharge
Long-term
SMART goal
Specific - define goal as much as possible: who, what, where, why, and which
Measurable - track progress and measure outcome
Attainable/achievable - goal is reasonable enough to be accomplished; goal isn’t out of reach or below standard performance
Relevant - goal is worthwhile and will meet the needs
Timely - time limit; establish sense of urgency and prompt nurse for time management
Why do we write and develop goals for the patient?
We want to have a positive change
- Within RN scope of practice/license
- Doesn’t require order
- Done in response to nursing dx
Independent interventions
- Ordered by doctor/provider, implement by RN
- Nurse is still responsible for the assessment/evaluation of the dependent intervention — make sure order is safe for the pt
Dependent intervention
Done with collaboration of health team members
Interdependent intervention
How to communicate task with the 5 rights of delegation
Right…
- Task, Circumstances, Person, Direction/communication, Supervision
5Rs - Delegable for a specific pt
Right Task
5Rs - Appropriate pt setting, available resources, and other relevant factors considered
Right circumstances
5Rs - Delegating the right task to the right person to be performed on the right person
Right person
5Rs - Clear, concise description of the task, including its objective, limits, and expectations
Right direction/communication
5Rs - Appropriate monitory, evaluation, intervention, and feedback
Right supervision
Who is responsible for the evaluation of the task delegated?
Nurse
- Evaluation that hasn’t been met
- Evaluation done while implementing care, immediately after care, and at each pt contact
Ongoing evaluation
Evaluation at specified stages, time, or intervals
Intermittent evaluation
- Evaluation that has ended, mark it as met and take it off the care plane
- The progress or status at discharge
- Includes forms or special instructions
Terminal evaluation
