UNIT 2 Flashcards
- Well-established, research supported framework for professional nursing practice
-It is accessible, adaptable, and adjustable high-step process consisting assessment, nursing diagnosis, planning, and the esblihment of goal and outcome criteria, implementation
-ensures the delivery of thorough individualized nursing care to patients regardless of age, gender, medical diagnosis, or setting.
nursing process
Major part of nursing process
- involves the use of the mind and thought processes to gather information and develop conclusion
Critical thinking
The elements of nursing process:
-physical
-emotional
-spiritual
-sexual
-financial
-cultural
-cognitive aspects
- data are collected, reviewed, and analyzed
- this allows you to formulate a nursing diagnosis related to the patient needs, specifically to drug administration
Assessment
Information about might come from the variety of sources including the
patient, patient’s family, caregiver, or significant other, and the patient’s chart.
Method of data collection includes:
interviewing, direct and indirect questioning, observation, medical records review, head-to-toe physical examination, and a nursing assessment
Data are categorized into:
objective and subjective data
Any information gathered through the senses; seen, heard, smelled
- may also be obtained by nursing physical assessment, nursing history, past/present medical history, results of laboratory test, diagnostic studies, procedures, measurements of vital signs, weight & height, and medication profile
objective data
data that comes from the patient
subjective data
Medication profiles include but are not limited to the ff information:
-any or all drug use
-use of home/folk/herbal remedies
-homeopathic treatment
-plant or animal extract
-dietary supplements
-intake of alcohol, tobacco, and caffeine
-current or history of illegal drug use
-use of over-the-counter medication such as: aspirin, paracatomol, etc
-family history
-ethnic or cultural attribution which attention to specific to different responses to medications as well as unusual individual responses
-growth and developmental stage
-issues relating to the patient’s age
A holistic nursing assessment includes:
-gathering of data about the whole of individual including the physical, emotional realms, religious preferences, beliefs, socio-cultural characteristics, race/ethnicity, lifestyle, socio-economic status, educational level, motor skills, cognitive level, support system
Include information shared through reliable sources such as: patient, spouse, family member, s/o, caregiver
subjective data
Once assessment of the patient or the drug has been completed, the specific prescription or medication order from the doctor or any prescriber must be check by the following 6 ELEMENTS
- patient’s name
-date of the drug ordered was written
-name of the drug - drug dosage amount and frequency
-route administration
-prescriber’s signature
-Developed by professional nurses as means of communicating and sharing information about the patient and patient’s experience
-result of critical thinking, creativity, accurate collection of data regarding the patient as well as the drug
Nursing diagnosis
Nursing diagnosis related to drug therapy will most likely to grow out of data associated with the ff:
deficient knowledge, risk for injury, non-compliance, and various disturbances, deficits, excess, impairments in bodily function, and or other problems and concerns as related to drug therapy
The development of classification of nursing diagnosis has been carried out by:
North American Nursing Diagnosis Association International (NANDA) (NANDAI)
After the data are collected and the nursing diagnosis are formulated according tot the medication and drug given to the patient
-The main purposes of this is to prioritize the nursing diagnosis, and specify goals and outcome criteria including the time frame for the achievement
Planning
Planning phase includes:
- identification of goals
- outcome criteria
-could be SHORT TERM GOAL or LONG TERM GOAL
Planning should be SMART. What is SMART?
Specific, Measurable, Attainable, Realistic, and Time-bound
Provides time to obtain special equipment for interventions, review the possible procedures or techniques to be used
-leads to provision of safe care if professional judgement is combined with acquisition of knowledge about the patient and medication to be given
Planning/ Planning phase
Are objective, measurable, and realistic, with an established time period for achievement of the outcomes
Goals
-Guided by the proceeding phases of the nursing process
- requires constant communication and collaboration
Implementation
Implementation may be:
Independent, dependent, collaborative