Unit 3: Nursing process, Ctiritcal thinking & Factors impacting patient care Flashcards
1
Q
Assessment:
A
How What Who When Where
2
Q
Assessment: How
A
Compiling a health history, physical examination, and analysis of diagnostic and lab results
3
Q
Assessment: Who
A
Client, family/significant others, healthcare team
4
Q
Assessment: What
A
• Client’s past history and current health status • Determinants of health • Subjective Data • Interview or conversation • Source: • Client • Family/Significant Others • Interprofessional team • Medical Records • Research Literature • Objective Data • Examination or assessment
5
Q
Assessment: When
A
- Occurs with every interaction
- 4 Types:
- Initial Assessment; what brought you in
- Focused Assessment
- Ongoing Assessment
- Emergency Assessment; ABC’s
6
Q
Assessment: Where
A
- Interview
- Start with their current illness and their concerns
- Their Experience: signs & symptoms, past medical experience, ADLs, lifestyle, desired outcomes, and participation
- Key is therapeutic communication: respect, empathy, and trust; with professional boundaries
- Verbal Communication
- Nonverbal Communication
- Tools and Forms
- Intake and history forms
- Screening Tools: MOCA, Falls Risk, Pain Assessment tools, OR checklist
- Physical Assessment
- Gather further information regarding the area of concern
- Include Head-to-toe assessments and vital signs
- Inspection, palpation, percussion and auscultation
- Review of diagnostic and lab results
7
Q
Nursing diagnosis
A
a clinical judgement that describes the client/family/community response to health conditions or life processes
8
Q
Planning
A
- Identify desired health outcomes
- Formulate Care plans
- Prioritize Appropriate Nursing Interventions
- Coordinate Resources
9
Q
Planning: Three types of planning
A
- Initial Planning
- Ongoing Planning
- Discharge planning
10
Q
Planning: Prioritization methods
A
- Maslow’s Hierarchy
- Synthesizing Information
- Setting SMART goals
11
Q
Implementation
A
• When what a nurse has planned is put into action
12
Q
What does implementation include?
A
- Reassessing the client
- Determining resources
- Implementing nursing interventions
- Delegation of Care
- DOCUMENTATION
13
Q
Evaluation
A
- You need to review the Care plan as a whole as well as its parts
- Review the clients response to interventions but also the resources provided
- Outcomes and evaluations will identify new assessment data used to identify new priorities and planning going forward.
14
Q
Types of care plans:
A
- Standards of care
- Standardized care plans
- Protocols
- Policies and procedures
15
Q
Elements included in Nursing Care Plans:
A
- Sign and date the plan
- Use category headings
- Used standardized & approved terminology
- Be specific
- Specific to patient
- Include prevention and health promotion principles
- Include discharge and home care plans
