W4: Nursing Process + Integ. System Flashcards
Critical thinking
Process nurses use to evaluate and interpret client data. Nurses learn to assess and modifty before acting. Evidence informed assessment is also vital to assessment.
Nursing Process
Systematic way to provide organize a care plan for clients. Organized through phases that creates a holsitic view and ensures pt focused personalized planning.
ADPIE
Assessment: collecting objective / subjective data
Diagnosis: analyze, interpret data
Planning: priotize issues and needs , interventions
Intervention: reassess pt, implement , document
Evaluation: collect data outcomes, see if interventions were sucess, reassess , modfiy , reflect plan.
Creating Nursing Diagosis Steps
- NADA Section I
- Section II: Match clients symptoms with medical diagosis, suggestions
- Section III- care plans listed based on Diagosis
- Nursing Assessment
- Acessment assess the data gathered from the client including pt symptoms , mental and physical state.
- Gathering Subjective data: primary source (paitent) and secondary sources ( medical records, family, care providers)
- Interview client
Gather objective data: General survey, physcial examination, vitals assess. Note info prior to next step
- Nursing Diagosis
Under section II, match the symptoms of client with the symptoms listed.
- Probelm Focused , risk for, health promotion
- Review data gathered, make a list of symptoms and match to nursing diagosis.
Analyzing Concerns
- Review data, is the data healthy
- Cluster simiarl symptoms
- Selected NADA diagosis and cluster such as ( ABC approach, Gordon patterns, system assessment)
How to write a nursing diagosis ?
Written in three portions: probelm , etiology, and symptoms PES
1. NANADA part of diagosis / problem + section I ( Over-weight)
2. Etiology/cause written as r/t ( related to) statement
3. Symptoms and signs: aeb ( r/t excessive intake aeb weight 20% over ideal “ as evidence by”
Three parts:
Clinical judgement regarding health issues at time: Over-weight related to excessive intake in related to (rt)
metabolic needs, concerning food intake at the end of the day as evidenced by (aeb) weight 20% over ideal for
height and frame (three-part nursing dx)
- Plan Interventions
Nursing interventions: guides care and sec III provides list
Setting Priorities
Priorities are the signs and symptoms reportd that can wait, and determinng what must be treated. If situation is life threatning, is data abnromal it must have priority.
Health Priority Settings
First level Issues: emergent, life threatning immediate ABC’s , must be addressed.
Second Level: urgent, prompting intervetions such as acute pain, lab results, risk for safety
Third: imporant only after more urgent issues are addressed. Stable.
Measuring Client Outcomes
- Measuring degree of pt changes is the response to expect. May be favorable or not so.
- Section III may provide client outcomes
- Use nurse outcome or client outcomes
- SMART goals
- Short term: outcomes achieved within a week, more immeidate , hours , a shift
- Long Term: outcomes achieved within weeks to months, used with more chornic health concerns.
Short / Long Temr Goals
Short Term: achieved SMART within a day or shift. Such as walk to end of hall by day 3.
Long Term take weeks to achieve, more for chronic related issues. Report releif from urinary incontiniuence within one month.
- Interventions
Section III
- Review data and select the intervention that best matches needs. Evidence based rationales , provide care following intervention. Whe choosing interventions, consider the diagosis, goals and outcomes, evidece, own competence.
Direct / Indirect Care
Direct care–> life saving meausres, ADL’s, teaching
Indirect–> communicating interventions, evaluate others work.
Types of Interventions
Nurse initated: interventions that don’t require direct orders
Physcian initaed; dependent on nursing interventions
Collab/interdependent: interventions require combined knowlege
Difference between intervention and outcome
Interventions: nurse actions to help pt achieve their goals , initaed by nurse in response to the diganosis. Such as client will be repoistioned, observe skin throughout. ( Conducted by the nurse to help achieve outcomes)
Outcomes: The clients goal , the measureable change in status response to care.
- Evaluation: Are goals met?
Determine effectiveness of the nursing interventions and client outcomes
- The clients goal is to be evaluated not the nurses intervention
- Compare actual outcomes with the exepcted ones
-Ongoing
- Analysis of client respones to nurse interventions
- if outcomes met, resolve plan, changes in diagosis, outcomes, interventions should be made.
Integumentary Skin Hair Nails Assessment ( IPPA)
Vital Signs + General survey, this part of head toe assessment involves inspection and papatation of the area.
What is the Subjective data ?
- Refers to assesment of the risk factors that affects the skin, hair, and nails
Questions asked regarding the following topics:
1. General health
2. Family History of skin condition
3. Past History
4. Medications and treatments
5. Allergies and nutrition
6. Lifestyle
7. Previous history of skin conditons
8. Mole changes ( color, size, shape)
9. Pigmentation
10. Dryness / moisture / itching (Puritis) / Rash or lesions
11. Bruising ( ecchymosis)
12. Sunbruns
13. Skin breakdown ( frinction, mositure)
How to prepare for a physcial examination?
- Wash hands, privacy, explain procedures, wear gloves
- Lighting
- Small ruler, penlight, gloves
What is the objective data?
Objective assessment: Inspection and palptation
General Assessment: Involves inspection and palptation of areas.
1. Nails: is nail pink bed, firm base, smooth nail angle 160, cap refill 2 sec, any nail clubbing , trimmed (IP). Non tender nail folds
2. Hair: Color, Texture, Distrubution ( IP)
3. Skin: understand baseline color, texture
- Color: obssereve color tone in all areas, freckles , sunspots. Note any jandice or cyanosis (blue) of area
- Temperature: using dorsal side of hand palpate skin bilaterally. Warm ( hypo/hyperthermia)
- Moisture: face, axilla, check for dehydration of mucos areas,
- Texture: should be smooth, thicker calluses ( edema is the buildup of fluid in the skin leaving indents.
- Mobility: Assess for elasticty of skin , check for dehydration by pinching. Tudor ( skin returns to place)
- Edema ( pressure indents)
- Lesions: palptate ligh brushes, Asymmetry, Boarders, color, diameter, evolution ABCDE
Objective data for Lesions
Lesions are to be oberved using ABCDE rules
- Color, elevation, pattern, size (6mm), location and distrubution
Promote self care and teach self skin exam using ABCDE (Assymetry, Boarder ireh=gular, color, diameter, elevation
Nurses role in Assessment ?
- To monitor skin integrity, prevent skin breakdown, healing
- General survey and physical examination of inspection and palpation
Edema
Skin that retains pressure indent
Various ways to quanitify +1, +2 +3 +4