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holistic nursing > week 5-nursing process > Flashcards

week 5-nursing process Flashcards

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
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
24
nursing diagnosis
focuses on the client's actual or potential reponse to a health problem rather than on the physiological event, complication or disease
25
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
26
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
27
what is NANDA stand for
North american nursing diagnostic association
28
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
29
why use the nursing diagnosis
-provides direction for the planning process and selection of nursing interventions to achieve desired outcomes for clients
30
what is a care plan
map for nursing care and demonstrates the nurse's accountability for client care
31
what do you do in the data analysis stage
-recognize pattern or trend by cues - compare with normal standards -make a reasoned decision
32
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
33
what are the components of a nursing diagnosis
-diagnostic label - related factors - definition - risk factors - support of the diagnostic statement
34
formulation of the nursing diagnosis
-actual nursing diagnosis -risk nursing diagnosis - health promotion diagnosis - wellness diagnosis
35
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)
36
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
37
expand on health promotion nursing diagnosis
clinical judgment of family, individual or community's desire/motivation to increase well-being and self-actualization
38
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)
39
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
40
examples of risk factors-nursing diagnosis
environmental, physiological, psychological, genetic, chemical elements that increase vulnerability
41
view chart on accountability in the nursing diagnosis
42
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
43
what does planning require
critical thinking, applied through deliberate decision-making and problem solving. establishing priorities
44
why must you establish priorities in the planning stage
helps nurses anticipate and sequence nursing interventions
45
classifications of priorities
high-priority nursing diagnoses intermediate-priority nursing diagnoses low-priority nursing diagnoses
46
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
47
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)
48
while goal setting
-mutual goal setting(nurse and client) -include client and fam to achieve goals -active participation-by all involved in client care
49
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
50
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
51

holistic nursing (5 decks)

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