WEEK 1 Flashcards
quoted “The very elements of nursing are all but unknown”
florence nightingale, 1859
is both A SCIENCE and AN ART that is concerned with the individual’s: Physical, Psychological, Sociological, Cultural, Spiritual
nursing
ESSENTIALS FEATURES OF THE NURSING PRACTICE
Full range of human experiences and responses to health and illness w/o restriction to a problem
focused orientation
Caring relationship that facilitates health and healing
Understanding and integration of objective data based on the client’s subjective experience
Knowledge for diagnosis and treatment
first step of the Nursing Process, The most important because it DIRECTS the rest of the process
Health assessment
“Combines the most desirable elements of the art of nursing with the most relevant elements of systems
theory, using the scientific method”
NURSING PROCESS, (shore, 1988)
This process incorporates an interactive/interpersonal approach with a problem solving and decision making process
nursing process, peplau 1952
nursing process is synonymous with the ___ approach
problem solving
gosh approach
goal oriented
organized
systemized
humanistic care
5 steps of the Nursing Process
- ASSESSMENT
- DIAGNOSIS
- PLANNING
- INTERVENTION
- EVALUATION
Systematic collection of data, The most important step, Sets the tone for the rest of the process, and the rest of the process flows from it, Identifies your patient’s strengths and limitations and is performed not just once, but continuously
throughout the nursing process
ASSESSMENT
Clinical judgment concerning a human response to health conditions / life processes, or
vulnerability for that response by an individual, family or community that the nurse is licensed and
competent to treat
diagnosis
s identifies an occurring health problem for your patient.
actual nursing diagnosis
identifies a high-risk health problem that most likely will
occur unless preventive measures are taken.
potential nursing diagnosis
one that needs further data to support it
possible nursing diagnosis
types of nursing diagnosis
problem focused
risk
health problem
syndrome
parts of nursing diagnosis
problem, etiology, signs and symptoms
Problem + Etiology + Signs and Symptoms
problem focused ND
Problem + Etiology
risk ND
problem only ND
health ND
Specific cluster of nursing diagnosis that occur together and have similar nursing
interventions to resolve the siyuation
syndrome ND
Observable assessment cues such as patient behavior, physical signs
defining characteristics
Etiological cause or causative factor for diagnosis
etiology.related factor
desired outcomes in the ADPIE, Appropriate interventions that Involves setting goals and outcomes, Individualized plan of care for your patient
planning
Ordering of nursing diagnoses or patient problems using notions of urgency and
importance to establish a preferential order for nursing interventions
priority setting
Broad statement that describes a desired change in a patient’s condition, perceptions or behavior
goals
objective behavior or response that you expect a patient to achieve over a
longer period, usually over several days, weeks or months
long term goals
objective behavior or response that you expect the patient to achieve in
short time usually few hours or less than a week
short term goals
Defined as any treatment based on clinical judgment and knowledge that a nurse performs to
enhance patient outcomes, Putting the plan of care into action
intervention/implementation
intervention approahces
direct
indirect
intervention types
independent
dependent
collaborative
Final step of the nursing process, crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process
evaluation
CHARACTERISTICS OF THE NURSING PROCESS
Dynamic and cyclic
Patient centered
Goal directed
Flexible
Problem oriented
Cognitive
Action oriented
Interpersonal
Holistic
Systematic
PURPOSES OF THE NURSING PROCESS
To identify a client’s health status; his Actual/Present and potential/possible health problems or
needs.
To establish a plan of care to meet identified needs.
To provide nursing interventions to meet those needs.
To provide an individualized, holistic, effective and efficient nursing care.
s the deliberate and systematic collection of data to determine a
client’s current and past health status and functional status and to determine the client’s present and
coping patterns.
assessment (carpenito)
a part of each activity the nurse does for and
with the patient.
assessment (afkinson and murray)
four basic types of assessment are:
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem-oriented assessment
Emergency assessment
Involves collection of subjective data about the client’s perception of his or her health of all body
parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered
during a step-by-step physical examination.
initial comprehensive assessment
Consists of data collection that occurs after the comprehensive database is established. This
consists of a mini-overview of the client’s body systems and holistic health patterns as a follow up on health status
ongoing or partial assessment
t does not replace the comprehensive health
assessment. It is performed when a comprehensive database exists for a client who comes to the
health care agency with a specific health concern
focused/problem oriented assessment
very rapid assessment performed in life-threatening situations. In such
situations
emergency assessment
performs a focused assessment, and then incorporates
assessment findings with a multidisciplinary team to develop a comprehensive plan of
care
acute care nurse
need enhanced assessment skills to safely assess
critically ill clients who are outside the structured intensive care environment
critical care outreach nurses
assess and screen clients to determine the need for physician
referrals.
ambulatory care nuses
make independent nursing diagnoses and referrals for collaborative
problems as needed.
home health nurses
assess the needs of communities, school nurses monitor the
growth and health of children, and hospice nurses assess the needs of the terminally ill
clients and their families
public health nurse
Nurses relied on their natural senses, palpation was used, f independent nursing practice using inspection, palpation, and auscultation
LATE 1800s–EARLY 1900s
American Journal of Public Health documents routine client and home inspection by public
health nurses
This role of case finding, prevention of communicable diseases, and routine use of assessment
skills i
1930–1949
Nurses were hired to conduct pre-employment health stories and physical examinations for major
companies, such as New York Telephone, from _____
1950–1969
s prompted nurses to develop an active role in the provision of primary health
services and expanded the professional nurse role in conducting health histories and physical
and psychological assessments
1970–1989
