week 5-nursing process Flashcards
what is application of the nursing process (theory)
-teaching and learning in holistic healthcare
- performing complete nursing assessments
what is the application of the nursing process (application)
-teaching and learning in holistic healthcare
- application of the nursing process
- performing complete nursing assessments
- role of documentation in the nursing process
the nursing process
ADPIE
assessment
diagnosis-nursing diagnosis
planning - outcomes identification
implementation
evaluation
nursing process cycle
continual re-evaluation-> theory/nursing science/underlying nursing concepts-> assessment/patient history-> Planning (nursing diagnosis, nursing outcomes, nursing interventions) -> implementation and back to re-evaluation
do the nursing process chat gpt role playing
assessment-nursing process
- data collection (subjective and objective data)
- data validation
- data organization
- analyze data
- data communication
diagnosis-nursing process
- data analysis and problem identification
- formulation of diagnostic statement
planning- nursing process
- set priorities
- identifying outcomes
- interventions
implementation-nursing process
- nursing based treatment
- physician based treatment
evaluation-nursing process
- data evaluation
- expected patient outcomes
- re-identification of problem
- discontinuation/modification of treatment
what is the purpose of critical thinking and assessment
- the deliberate and systematic collection of data from a primary source and secondary sources
- determines a client’s current and past health status and functional status
-determines a client’s current and past coping patterns - establishes an individualized database
- critical thinking enables the nurse to have a broader perspective
- data are collected in a way that elicits openness from the client
types and example of considerations
cultural assessments
- conduct any assessment of cultural safety
indigenous health assessment:
-skill based training is needed in intercultural competency, conflict resolution, human rights and antiracism
- the focus is on building trust and therapeutic relationships
what does assessment look like
-nursing health history
- differentiating essential data from the total data collected: subjective (verbal description of the condition) and objective (clinical measurements/assessments)
- cute
- inference
- id emerging patterns and potential problems
sources of data
primary-client
secondary
- family and significant others
- health care team
- medical records
tertiary sources
- literature-evidence-informed info
- nurse’s experience
data collection methods
interview
nursing health history
family history
documentation of history findings
what happens in the interview
-organized convo with client
open-ended questions
closed-ended questions
orientation phase
working phase
termination phase
when is the info gathered for the nursing health history
gathered during initial or early contact
what are you looking for when gathering family history
genetic illness, family structure and social support
when taking the health history holistically
-ID data
- source of history
- reason for health history interview
- current state of health
- developmental variables
- psychological variables
- spiritual variables
- sociocultural variables
- physiological variables (history of previous illnesses and injuries, current meds, review of systems)
types of health histories
comprehensive
problem-based/problem-focuses
follow up/episodic
strength based
comprehensive-health history
-on admission, when not critically problemill, takes more time bc complete database is formed
problem based/probelm focused health history
data that is limited in scope to a specific problem but detailed so nurse is aware of other health-related data that could impact the problem, more data collected later on when they are stabilized
follow up/episodic health history
focuses on a problem or problems when a patient has already been receiving treatment
strength based health history
-family nursing
- places person at centre of care
considers goals and dreams of the individual
- promotes empowerment, self-efficacy and hope
what is physical history/what do you do for it
-observation of client’s behaviour
- diagnostic and lab data
-interpreting assessment data and making nursing judgments…data validation, analysis and interpretation
nursing diagnosis
focuses on the client’s actual or potential reponse to a health problem rather than on the physiological event, complication or disease
what do you do for data analysis
-recognize pattern or trend by cues
- compare with normal standards
- make a reasoned decision
- concept map is useful here
expressed as a nursing diagnosis
types of diagnoses
nursing-clinical judgement abt client responses to a health problem
medical-ID of a disease/condition based on signs and symptoms
collaborative-actual or potential complication that nurses monitor to detect a change in client status
what is NANDA stand for
North american nursing diagnostic association
why use NANDA
-translates nursing observations and assessments into standard conclusions in a common nomenclature
-precise definition of client’s needs
- common language for the healthcare team
-clinical judgement concerning a human response to health conditions/life processed or vulnerability for that response, by an individual, family, group or community
why use the nursing diagnosis
-provides direction for the planning process and selection of nursing interventions to achieve desired outcomes for clients
what is a care plan
map for nursing care and demonstrates the nurse’s accountability for client care
what do you do in the data analysis stage
-recognize pattern or trend by cues
- compare with normal standards
-make a reasoned decision
what is part of the nursing diagnosis process3 things
diagnostic reasoning…process of using assessment data to create a nursing diagnosis
defining characteristics…clinical criteria or assessment findings that help confirm an actual nursing diagnosis
clinical criteria…objective or subjective signs and symptoms that lead to a diagnostic conclusion
what are the components of a nursing diagnosis
-diagnostic label
- related factors
- definition
- risk factors
- support of the diagnostic statement
formulation of the nursing diagnosis
-actual nursing diagnosis
-risk nursing diagnosis
- health promotion diagnosis
- wellness diagnosis
expand on actual nursing diagnosis
-responses to health/life conditions in individual, family, community
-consists of defining characteristics that cluster in patterns
-must have enough data to make diagnosis
-prioritized in order of importance (BAC)
expand on risk nursing diagnosis
-responses to health conditions that possibly will develop in a vulnerable population.
-data should include factors as to why it would increase the vulernability
expand on health promotion nursing diagnosis
clinical judgment of family, individual or community’s desire/motivation to increase well-being and self-actualization
expand on wellness diagnosis
clinical judgement abt the individual, community, family in transmit from one level of wellness to another, client wishes to achieve optimal health (used in cancer diagnoses)
components of the nursing diagnosis
diagnostic label-determined by NANDA, use descriptors ex impaired. contains qualifier and FOCUS
related factors “related to”- individualizes the client’s diagnosis so the care is personalized. NOT A MEDICAL DIAGNOSIS
definition-describes the characteristic of human response
risk factors
support of diagnostic statement “as evidenced by”…assessment data that supports the nursing diagnosis
examples of risk factors-nursing diagnosis
environmental, physiological, psychological, genetic, chemical elements that increase vulnerability
view chart on accountability in the nursing diagnosis
planning-when and what
-begins after ID of a client’s nursing diagnoses and strengths
-sets client-centered goals and expected outcomes, plans nursing interventions and prioritizes interventions
what does planning require
critical thinking, applied through deliberate decision-making and problem solving. establishing priorities
why must you establish priorities in the planning stage
helps nurses anticipate and sequence nursing interventions
classifications of priorities
high-priority nursing diagnoses
intermediate-priority nursing diagnoses
low-priority nursing diagnoses
what are the 3 phases of planning care
initial-immediately after analysis of data
ongoing-based on the evaluation of strategies
discharge- when a client goes home or is discharged from care
types of goals-planning
client centered-focused on client’s needs. specific and measurable behavioural response that reflects highest level of wellness and independence
short term-achievable in less than 1 week
long term- achievable over longer period of time (days, weeks, months, years)
while goal setting
-mutual goal setting(nurse and client)
-include client and fam to achieve goals
-active participation-by all involved in client care
what are outcomes
-specific measurable change in a client’s status that is expected due to nursing care
- provide focus or direction
- determine when a specific client-centred goal has been met
-nursing sensitive client outcome
guidelines for writing goals
-client’s goals or outcome
-singular goal or outcome
- observable goal or outcome
- measurable goal or outcome
- time-limited goal or outcome
- mutual goal or outcome
- realistic goal or outcome
