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holistic nursing > week 5-nursing process > Flashcards

week 5-nursing process Flashcards

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1
Q

what is application of the nursing process (theory)

A

-teaching and learning in holistic healthcare
- performing complete nursing assessments

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2
Q

what is the application of the nursing process (application)

A

-teaching and learning in holistic healthcare
- application of the nursing process
- performing complete nursing assessments
- role of documentation in the nursing process

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3
Q

the nursing process

A

ADPIE
assessment
diagnosis-nursing diagnosis
planning - outcomes identification
implementation
evaluation

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4
Q

nursing process cycle

A

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

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5
Q

do the nursing process chat gpt role playing

A
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6
Q

assessment-nursing process

A
  1. data collection (subjective and objective data)
  2. data validation
  3. data organization
  4. analyze data
  5. data communication
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7
Q

diagnosis-nursing process

A
  1. data analysis and problem identification
  2. formulation of diagnostic statement
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8
Q

planning- nursing process

A
  1. set priorities
  2. identifying outcomes
  3. interventions
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9
Q

implementation-nursing process

A
  1. nursing based treatment
  2. physician based treatment
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10
Q

evaluation-nursing process

A
  1. data evaluation
  2. expected patient outcomes
  3. re-identification of problem
  4. discontinuation/modification of treatment
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11
Q

what is the purpose of critical thinking and assessment

A
  • 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
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12
Q

types and example of considerations

A

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

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12
Q

what does assessment look like

A

-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

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12
Q

sources of data

A

primary-client

secondary
- family and significant others
- health care team
- medical records

tertiary sources
- literature-evidence-informed info
- nurse’s experience

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13
Q

data collection methods

A

interview
nursing health history
family history
documentation of history findings

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14
Q

what happens in the interview

A

-organized convo with client
open-ended questions
closed-ended questions
orientation phase
working phase
termination phase

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15
Q

when is the info gathered for the nursing health history

A

gathered during initial or early contact

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16
Q

what are you looking for when gathering family history

A

genetic illness, family structure and social support

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17
Q

when taking the health history holistically

A

-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)

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18
Q

types of health histories

A

comprehensive

problem-based/problem-focuses

follow up/episodic

strength based

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19
Q

comprehensive-health history

A

-on admission, when not critically problemill, takes more time bc complete database is formed

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20
Q

problem based/probelm focused health history

A

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

21
Q

follow up/episodic health history

A

focuses on a problem or problems when a patient has already been receiving treatment

22
Q

strength based health history

A

-family nursing
- places person at centre of care
considers goals and dreams of the individual
- promotes empowerment, self-efficacy and hope

23
Q

what is physical history/what do you do for it

A

-observation of client’s behaviour
- diagnostic and lab data
-interpreting assessment data and making nursing judgments…data validation, analysis and interpretation

24
Q

nursing diagnosis

A

focuses on the client’s actual or potential reponse to a health problem rather than on the physiological event, complication or disease

25
Q

what do you do for data analysis

A

-recognize pattern or trend by cues
- compare with normal standards
- make a reasoned decision
- concept map is useful here

expressed as a nursing diagnosis

26
Q

types of diagnoses

A

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

27
Q

what is NANDA stand for

A

North american nursing diagnostic association

28
Q

why use NANDA

A

-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

29
Q

why use the nursing diagnosis

A

-provides direction for the planning process and selection of nursing interventions to achieve desired outcomes for clients

30
Q

what is a care plan

A

map for nursing care and demonstrates the nurse’s accountability for client care

31
Q

what do you do in the data analysis stage

A

-recognize pattern or trend by cues
- compare with normal standards
-make a reasoned decision

32
Q

what is part of the nursing diagnosis process3 things

A

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

33
Q

what are the components of a nursing diagnosis

A

-diagnostic label
- related factors
- definition
- risk factors
- support of the diagnostic statement

34
Q

formulation of the nursing diagnosis

A

-actual nursing diagnosis
-risk nursing diagnosis
- health promotion diagnosis
- wellness diagnosis

35
Q

expand on actual nursing diagnosis

A

-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)

36
Q

expand on risk nursing diagnosis

A

-responses to health conditions that possibly will develop in a vulnerable population.
-data should include factors as to why it would increase the vulernability

37
Q

expand on health promotion nursing diagnosis

A

clinical judgment of family, individual or community’s desire/motivation to increase well-being and self-actualization

38
Q

expand on wellness diagnosis

A

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)

39
Q

components of the nursing diagnosis

A

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

40
Q

examples of risk factors-nursing diagnosis

A

environmental, physiological, psychological, genetic, chemical elements that increase vulnerability

41
Q

view chart on accountability in the nursing diagnosis

A
42
Q

planning-when and what

A

-begins after ID of a client’s nursing diagnoses and strengths
-sets client-centered goals and expected outcomes, plans nursing interventions and prioritizes interventions

43
Q

what does planning require

A

critical thinking, applied through deliberate decision-making and problem solving. establishing priorities

44
Q

why must you establish priorities in the planning stage

A

helps nurses anticipate and sequence nursing interventions

45
Q

classifications of priorities

A

high-priority nursing diagnoses
intermediate-priority nursing diagnoses
low-priority nursing diagnoses

46
Q

what are the 3 phases of planning care

A

initial-immediately after analysis of data
ongoing-based on the evaluation of strategies
discharge- when a client goes home or is discharged from care

47
Q

types of goals-planning

A

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)

48
Q

while goal setting

A

-mutual goal setting(nurse and client)
-include client and fam to achieve goals
-active participation-by all involved in client care

49
Q

what are outcomes

A

-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

50
Q

guidelines for writing goals

A

-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

51
Q
A

holistic nursing (5 decks)

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