Week 1 Flashcards
What is the Nursing process
ADPIE
Assessment
Collect and analyze data
Medical diagnosis
Focuses on disease and pathology
Nursing diagnosis
Focuses on patient response to illness
How is data used
By other disciplines
For Nursing Care
To ensure clients receive
-proper care
-by qualified individuals
-at the correct time
Cana RN delegate assessment
No.
CNA and LPNs can collect data such as vital signs. However it is the RNs responsibility to assign those tasks, confirm accuracy of data, conduct interview and do physical assessment.
What are the types of data
Objective, subjective, primary, and secondary
Objective data
Data the nurse observes.
Data that comes from lab, etc.
Can be measured
Subjective data
What the patient reports
Primary data
Obtained directly from the patient or observed the patient.
Vitals.
Secondary data
From someone other than patient. Includes patient record.
Skills of the nursing assessment/how to obtain data
Observation
Physical assessment
Interviewing
Nursing interview
Structured communication
To gather subjective data
Can be done direct or nondirect
Directive interview
Closed ended. Nurse in charge
Nondirective interview
Open ended.
Patient in charge.
When to verify data
Subject and objective data conflict
Clients statement are inconsistent
Data is far out of normal range
Factors that impact accuracy are present
Documentation Guidelines
-do so soon as possible
-rarely use acronyms
-use patient’s own word when possible
-use concrete specific information
-document cues but not inferences
Diagnosis
Analyze and interpret the data
Draw conclusion
Very conclusion
Prioritize problems
Health problem
Disease or illness that requires intervention
Nursing Diagnosis
Health problem that nurse identifies, prevents, or treats independently.
Diagnostic reasoning
Use critical thinking to analyze and interpret data
Draw conclusions about health status
Verify problems with client
Record diagnostic statement
Prioritizing problem
Maslows hierarchy of needs guides priority for nurses. Multiple problems can be addressed at once.
Priority levels
High-life threatening
Med-may causes serious physical or emotional changes
Low-requires minimal nursing intervention
Planning
Select standard care plan
Create individualized care plan
Identify outcomes and goals
Initial planning
-Begins at first client contact
-Done shortly after initial assessment
-development of initial comprehensive care plan
Ongoing planning
Changes made as client responds to care
Discharge planning
-self care and continuity of care after discharge
-Begins with initial assessment
-Requires collaboration
Process for writing individualized care plan
Make list of problems
Identify which problems can be addressed with standardized care plan
Individualize standard care plan
Include ADLs and basic care needs
Develop individualize care plans for the problems not addressed by standardized care plan
Goals/outcome
Goals: Change in health status that we hope to achieve
Nursing sensitive outcomes: can be influenced by nursing interventions
Long term goals
Achieved over week or more
Short term goal
Few hours to few days
Planning intervention
Review diagnosis and outcome
Select standardized intervention
Individualize to meet patient needs
Nursing intervention classification
Has label, definition, and list of activities
Are linked to Nanda-1 diagnosis and NOV outcome labels
Nursing orders
Date
Subject
Verb
Times and limits
Signature
What is a nursing order
Instructions on how and when nursing interventions will be implemented
Usually on nursing care plan
Possibly can be delegated
RN may delegate but remains accountable for the patient
Safe Nursing orders
Provide goal directed, client centered care
Use evidence based care
Provide safe quality care
Implementation
Promote client participation
May delegate but remain accountable(most include supervision)
Can not delegate intervention that requires independent specialized nursing skill
Five rights of delegation
Right task
Right curcumstance
Right person
Right direction
Right supervision
Final step of implementation
Documentation.
Record nurses activities and client response.
Evaluation
Evaluate clients progress to goals
Effectiveness of nursing care plan
Quality of care in health care setting
Types of evaluation
Structure
Process
Outcomes
Structure
Focuses on setting where care is provided.
Explores how the organizations policies and procedures impact quality of care.
Process
Focuses on the way care is provided.
The activities by RN and other members of teams.
Was care relevant, appropriate, etc.
Outcomes
Focuses on measurable change in clients health as result of care
Frequency and time of evaluation
Ongoing
Intermittent
Terminal
Ongoing
Will continuously evaluate while implementing, after interventions, and every patient contact
Internittent
Done at specific times
Terminal
Describes patient health and progress towards goal when they are discharged.
How to evaluate client progress
Review outcomes
Collect reassessment data
Judge goal achievement
Record evaluative statement
Evaluate collaborative problems
Evaluating and revising care plan
Goals met-if all goals met discontinue care plan
Goals partially met-can revise care plan or give more time to achieve goal
Goals not met- examine entire care plan and see if revision is necessary
Revise care plan-must review each step of nursing process to decide how to revise care plan
Checklist for evaluating care plan
Review assessment- changes may have occurred in data or client condition
Review diagnosis- diagnosis may require update
Review planning outcomes-outcome might need to be revised
Review planning interventions-might need to modify nursing orders
Review implementation-can be failure to implement or issues with how implementation occurred.
Types of assessments
Initial and ongoing-are as their definition
Comprehensive -hollistic
Focused -targets specific problem
Special needs assessment
Special needs assessment
Type of focused assessment that focuses on one area
Nutritional assessment
Pain asessment
Cultural assessment
Spiritual health assessment
Psychosocial assessment
Etc.
Nursing health history
Is done during assessment.
Usually includes:
chief complaint
History of present illness
Past health history
Different problem types (diagnostic reasoning)
Medical diagnosis
Collaborative problem
Actual nursing diagnosis
Risk nursing diagnosis
Possible nursing diagnosis
Syndrome nursing diagnosis
Patient stregths
Wellness nursing diagnosis
