Unit 3 and 4 Flashcards
What are the purposes of the systematic approach used by all nurses (besides LPNs)?
Gather, critically examine, and analyze data.
Identify client responses.
Design outcomes.
Take appropriate interventions.
Evaluate the effectiveness of interventions.
What is the nursing process?
A - Assessment D - Diagnosis P - Planning I - Implementation E - Evaluation
What is the purpose of the Assessment phase?
Gather data
What is the purpose of the Diagnosis phase?
Identify PT’s health needs
What is the purpose of the Planning phase?
Goal outcomes - What do I want PT to achieve?
Interventions - How to get there
What is the purpose of the Implementation phase?
Put into action
What is the purpose of the Evaluation phase?
Did our implementations work?
T/F - Per the ANA, assessments are a professional responsible of nurses
True
T/F - Legal actions are plausible if assessments are not done well
True
Assessment
The systematic gathering of information (data) r/t the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community.
Written, comprehensive, gather info.
What are the 5 steps needed to perform a systematic assessment?
Step 1 - Data collection
Step 2 - Organize data - spiritual, emotional, mental - Holistically organized
Step 3 - Validate data - is the data correct/accurate?
Step 4 - Clustering/grouping data to identify patterns to analyze data
Step 5 - Record + Report data - Document, report vital into
Critical info must be reported within what time frame? Example of critical info? Reported to who?
Within 1 hour, critical lab values, reported to someone who can do something about it
What are the 2 types of data?
Subjective
Objective
Subjective data
Symptoms from pt, CAN NOT be measured, direct quotes from pt. Include clients feelings, perceptions, and descriptions of health status. ex: “I do not feel good”
Objective data
Signs, more reliable, from the source and CAN be measured. These are findings observed and measured during physical examination. Feel, see, hear, and smell through observation or physical examination. ex: BP 120/80
What is an example of both subjective and objective data at once?
Pain scale 1-10 is the pt verbally telling you how much they’re in pain, but it is measurable.
What are the two sources of data?
Primary, Secondary
What is a primary source of data?
From the source itself. From the pt, or health care provider for a confused pt (Alzheimers and HCW saying the pt is confused)
What is a secondary source of data?
From someone other than the source. Example: wife of a husband pt, parent to a child pt, confused Alzheimer’s pt
Assessment: Data Collection - Methods of Data Collection? (4 listed in powerpoint)
Observation
Interview
History collection
Physical Examination
(Also listed: “Other sources of Data Collection”, no examples given in class)
Data Collection: Observation
“hallway observation”; 4 senses - see, hear, smell, touch; general appearance - agitated, calm, alert and oriented, color, age (does chronological age match?), how do they interact?
Data Collection: Interview
getting info; establish nurse-patient relationship before asking questions.
Consider age and development (child, teen, middle aged, etc..)
Open ended questions.
No “why” questions - leads to defensive answers.
Listen actively - nod, validate, reflective questions, no interrupting
Data Collection: History collection
Gathering - previous diagnosis, past history, maintenance/management? prescription changes
Data Collection: Physical examination
Head to toe assessment in systematic manner
What is the goal of data collection?
Identify health problems and opportunity for nursing interventions
Are lab values primary or secondary data?
Primary
Is a nurses report primary or secondary data?
Secondary
How is collected data used?
to create care plan for pt
What are the types of assessments? (6 listed in powerpoint)
Initial/Admission Focused assessment Comprehensive/Shift Emergency assessment Time-Lapsed Special Needs
What is the purpose of an initial/admission assessment?
Establish complete, comprehensive database on pt.
Baseline data.
Are there problems with the pt?
There is a certain amount of time to complete this assessment - get it done sooner than later to establish proper baseline data
What is the purpose of a focused assessment?
Gather ongoing data about specific problems that already has been identified.
Patient w/ pneumonia? Check respiratory/cardiovascular.
Focus on problem area.
What is the purpose of a comprehensive/shift assessment?
Establish prioritization and continuous data collection. Do things match for your received hand off report? Establish your baseline data for your shift.
What is the purpose of an emergency assessment?
Identify life-threatening conditions.
ER uses this a lot.
What is the purpose of a time-lapsed assessment?
Compare patient health status to baseline.
Periodic assessment checks. Used a lot in LTC facilities.
What is the purpose of a special needs assessment?
Specific to certain patient populations.
Ex: nutritional/BMI of 15 = low. Need more info from pt, dietary consult/referral.
Function impaired? PT/OT
What is the difference between medical vs. nursing assessments?
Medical assessments focus on DISEASE and PATHOLOGY.
Nursing assessments focus on patient RESPONSES to illness. Treating signs/symptoms and patient.
Can nurses delegate an assessment?
Only to another nurse. Be aware of scope of practices.
Can nurses delegate vital signs to an LNA?
If the patient is stable. If the patient is unstable, vital signs are considered an assessment, so NO.
Why is clustering data important?
Allows patterns to be recognized.
Helps to identify nursing diagnosis pertinent to your pt
How can you cluster data?
According to a model or framework (ex: body system, Maslow’s basic human needs model, etc).
By body system or need deficit
How should data be reported when assessment findings are critical? Time frame?
VERBALLY and immediately, within 1 hour!
Is documentation legally binding?
Yes!!! and If you did not document, it did not happen.
When should you document?
ASAP, immediately if possible.
What is effective documentation?
Consistent, clear, concise, thoughtful, timely, sequential, reflective of nursing practice, universal language. ONLY APPROVED ACRONYMS.
Write legibly and type correctly
Avoid using inferences
Use pt’s own words - Quotes, do not chart anything not relevant.
A good way to chart no new orders from Dr:
“Patients vitals _____, Patient symptomatic, No new orders received.
Record only _________, ________, and _________ data.
Pertinent, Important, Relevant
What are the formats of documentation? (3 listed in powerpoint)
1) Charting by exception - only chart abnormalities from baseline. “respiratory assessment within normal limits.”
2) Problem oriented medical record - problem focused, organizes data around the pt’s problem rather than the sources of information.
3) SOAP - subjective, objective, assessment, plan
SBAR
tool of communication.
Situation, background, assessment, recommendation
How is critical thinking used in nursing diagnosis?
Using critical thinking skills to identify patterns in the assessment data and draw conclusions about the pt’s health status.
PPT Unit 3 part 2, slide 12
Identifying Nursing Diagnosis
Common language for nurses, a clinical judgement.
Provides a basis for selection of nursing interventions so that goals and outcomes can be achieved.
NANDA list of acceptable diagnoses
What is nursing accountability?
Nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
What are the 3 main types of nursing diagnosis?
1) Problem-Focused Nursing Diagnosis
2) Risk Nursing Diagnosis
3) Health Promotion Nursing Diagnosis
Problem-Focused Nursing Diagnosis
Actual problem, typically 3 signs/symptoms to prove.
Actual evidence of s/s of diagnosis exist.
Ex: Fluid volume deficit
Risk Nursing Diagnosis
Potential/Risk for a problem, maybe 1 sign/symptom.
Database contains risk factors of diagnosis, but no true evidence.
ex: risk for altered skin integrity
Health Promotion Nursing Diagnosis
Describes health status, but not a problem. AKA Wellness Diagnosis.
Ex: Readiness for enhance comfort.
What are the 5 steps to Diagnostic reasoning/Clinical judgement?
Analyze & interpret, Draw conclusions, Verify problems, Prioritize, Record
Acronym for Diagnostic Statement
P.E.S.
Problem (nursing diagnosis), Etiology (r/t), Signs and Symptoms (AEB)
r/t = related to
AEB = as evidenced by
Ex: Impaired skin integrity r/t immobility aeb stage III decubitus ulcer, red inflamed skin, purulent
What are the don’t’s of writing a nursing diagnosis? (2 listed in powerpoint)
Don’t use Medical Diagnosis (Altered nutritional status r/t CANCER)
Don’t state 2 separate problems in one diagnosis
ex: “anxiety and fear r/t…”
Needs 2 separate diagnoses and 2 r/t’s and possible different therapies.