week five Flashcards
Nursing Diagnosis
Clinical judgement/patient problem about responses to health problems or life processes that nurses are licensed to treat
Etiology
The probable cause of the problem joined with r/t. can not be medical diagnosis.
dx
diagnosis
Subjective Data
Things a person tells you about that you cannot observe through your senses; symptoms
Objective Data
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
Interview
meeting between examiner and patient with the goal of gathering a complete health history
Physical Health Assessment (Examination)
an evaluation made for the purpose of diagnosis by identifying physical evidence of disease, such as signs and symptoms
Assessment
Collecting data, organizing data, validating data, documenting data
Diagnosis
Analyzing data, identifying health problems, risks, and strengths, formulate diagnostic statements
Planning
Prioritizing problems/diagnoses, formulating goals/desired outcomes, selecting nursing interventions
Implementing
Reassess client, determine nurse’s need for assistance, implement the nursing interventions, supervise delegated care, document nursing activities
Evaluating
Collect data related to outcomes, compare data with outcomes, relate nursing actions to client goals/outcomes, draw conclusions about problem status
Describe the relationship between critical thinking and the nursing process
Critical thinking is the purposeful, reflective, mental activity using skills in reasoning, analysis and decision making relevant to the discipline of nursing. The nursing process is a systematic approach to the delivery of nursing services.
Describe the step in assessment: Collect Data
gather information about a patient’s health status using information that comes from the patient (primary source, or family, health records, other health professionals (secondary source).
Describe the step in assessment: Organize Data
Written or electronic format organize the collected patient data systematically
Describe the step in assessment: Validate Data
Double-checking of gathered data to confirm it is accurate and factual. Not all data requires validation.
Describe the step in assessment: Document Data
Data are recorded in a factual manner without interpretation by the nurse. Subjective data should be documented in the patient’s own words and in quotes.
Data Collection Methods: Interview
planned communication. Directive: structured for specific information - nurse controls. Non Directive: build rapport, patient controls. The three stages of an interview are the opening, body, and closing.
Interview Opening
Sets the tone, establishes rapport and states the purpose for the interview
Interview Body
Communication phase, data collection
Interview Closing
Nurse or patient end the conversation, important for building trust and continuing rapport
Data Collection Methods: Physical Assessment
Inspection, palpation, percussion, auscultation
Inspection
visual examination, purposeful and systematic, must have sufficient lighting
Palpation
Sense of touch, determine texture, temperature, position, size, distention, mobility of organs, pulsation, presence of pain
Percussion
Striking or tapping the body surface so that sounds can be heard or vibrations felt
Auscultation
Listening to sounds produced within the body. Can be direct (with ear alone) or indirect (with a stethoscope)
Actual Nursing Diagnosis
The problem is present at the time of assessment
Risk For Nursing Diagnosis
The problem does not currently exist, BUT based on the RN’s clinical judgement there are risk factors that indicate that a problem is likely to develop without RN intervention
Wellness Nursing Diagnosis
Focuses on the patient’s desire to maintain or increase current level of health/wellness. “Readiness For”
dx
Diagnosis
Substantiating Data
What you actually observe/find in your patient that explains/validates the defining characteristics you have chosen.
Defining Characteristics
the clinical criteria or assessment findings that support an actual nursing diagnosis
Risk Factors
factors linked with a disease by association but not yet proved to be cause of an actual disease in the patient.
Collaborative Problem
Both medical and nursing interventions are needed to prevent and treat the problem. Begin with statement “Potential complication”
Medical Diagnosis
Problem with the structure or function of an organ or body system requiring diagnosis and treatment by a physician
NANDA
North American Nursing Diagnosis Association International
Steps of Diagnostic Phase: Analyzing and Interpreting the Data
compare the data you have collected against what is expected, is the data normal or abnormal, what type of problem does the abnormal data point to, look for gaps or inconsistencies
Steps of Diagnostic Phase: Clustering the Data
done after assessment, organize data and look for common patterns, review patient responses and symptoms, identify gaps and inconsistencies
Steps of Diagnostic Phase: Identifying Health Problems, Risks, and Strengths
Joint effort between nurse and patient, determine if problem is a nursing diagnosis, medical diagnosis, or a collaborative problem
Steps of Diagnostic Phase: Formulating Diagnostic Statements
This is a 2 part statement including a patient problem or diagnostic label from the NANDA list and the etiology or probable cause of that problem joined with r/t. Etiology must be within the domain of nursing practice and not the medical diagnosis.
Health
Many definitions of health. “An experience of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Incorporates a personal perception of well-being as well as can be expressed on a continuum
Well-Being
Well being is subjective, perception, and personal opinion of health status
Wellness
A state of well-being, a personal responsibility, a process, daily choices/decision, an ultimate goal, holistic and individual
Emotional Wellness
recognize your feelings, accept your personal limitations, manage your stress, express your feelings appropriately
Physical Wellness
maintain adequate nutrition and hydration, achieve proper level of body fat proportion, support fitness of all body systems, avoid excessive use of alcohol or abuse of drugs, including prescribed medications, avoid risky behaviors
Social Wellness
love and belonging, develop respect and tolerance of other’s differences, interact successfully with others within their environment, maintain intimacy with those close to you
Environmental Wellness
improve your community’s standard of living, promote local quality of life, buy locally grown foods and services, support healthy air quality, sustain water resources
Occupational Wellness
develop a balance for work and personal life, acknowledge your beliefs regarding education, employment, and personal life and seek to understand others beliefs, one’s personal beliefs effect their relationships with others
Spiritual Wellness
human beings believing in a uniting force such as religion, nature, science, or a higher power, belief provides meaning and purpose to life, this belief forms and supports one’s morals, values, and ethics
Intellectual Wellness
ability to learn, develop thoughts and reasoning for use in developing career, personal and family life, ability to cope with challenges and problem solve, to learn ,retain, and use knowledge
What are the components of the health/illness continuum?
pre-mature death, disability, symptoms, signs, neutral point, awareness, education, growth, high-level wellness
Factors that may affect health status, beliefs, or practices
Internal Dimensions: biologic, psychological, cognitive. External Dimensions: environment, standards of living, family and cultural beliefs, social support networks
Levels of Prevention: Primary Prevention
Promotion or protection
Levels of Prevention: Secondary Prevention
Screening/early identification and/or treatment to prevent complications
Levels of Prevention: Tertiary Prevention
Training, Teaching
What is the nurse’s role in health promotion?
role model, facilitator, teacher/educator, advocate, coordinator of services, consultant
What are the central goals of Healthy People 2020?
Vision: a society in which all people live long healthy lives. Key Components: risk assessments, public health priorities, health preparedness and prevention. Federally funded and high on health continuum.
What are the effects of hospitalization/institutional living on clients?
behavioral and emotional changes, self-concept changes, body image changes, lifestyle changes, loss of independence, financial concerns, role changes, increase stress, change in social norm or structure
Examples of inpatient settings
hospitals, extended or long term care, retirement community or assisted living, rehabilitation centers, sub-acute centers, hospice houses or centers
Examples of outpatient setting
ambulatory care centers (clinics), MD/primary care offices, occupational or industrial health clinics, out-patient, urgent care, child or adult day-care, crisis centers/support groups, home care/public health
Levels of long term care
Skilled Nursing Facility, Assisted Living, Independent living for seniors, residential care facilities (disabilities)
Skilled Nursing Facility
offers skilled care from a licensed nursing staff until clients are able to move back into the community or into residential care
Assisted Living
facilities where residents live who need some assistance; they do not usually require skilled care.
Independent living
allow self-care individuals to rent or purchase an apartment in the facility; provide services such as meals, housekeeping, laundry, transportation, social events, and basic medical care.
Residential Care Facilities
sheltered environments that do not provide professional healthcare services and thus for which most health insurance programs do not provide coverage. Mainly for people with disabilities
What is the role of the community health nurse?
advocate, caregiver, care manager or coordinator, educator
What services are available in the home setting?
less expensive, familiar surroundings, family involvement, improved client outcomes, enhanced quality of life
Hospice
a program of medical and emotional care for the terminally ill
Urgent Care Center
delivery of ambulatory care in a facility dedicated to the delivery of care outside of a hospital emergency department, usually on an unscheduled, walk-in basis. Urgent care centers are primarily used to treat patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency room
Crisis Intervention Center
secondary prevention: help people deal with short term stressful sitch requiring immediate therapeutic attention
Day Care Center
day care centers provide treatment during the daylight hours with patient being released at night. Child and Adult.
Home Care
provides nursing, therapy, personal care or housekeeping services in the patient’s own home
Rehabilitation Center
A facility that offers care for patients with ongoing recovery from a disability. This can include medical, psychiatric, or physical therapy.
Define Nursing Diagnosis: Falls, risk for
Increased susceptibility to falling that may cause physical harm
Risk Factors for Falls, risk for
Age 65 or older, history of falls, lives alone, lower limb prosthesis, use of assistive devices, wheelchair use, less than 2 years of age, bed located near window, lack of automobile-restraints, lack of gate on stairs, lack of window guard, lack of parental supervision, male gender when less than 1 year of age, unattended infant on elevated surface, diminished mental status, cluttered environment, dimly lit room, no antislip material in bath, no antislip material in shower, restraints, throw rugs, unfamiliar room, weather conditions, angiotensin-converting enzyme (ACE) inhibitors, alcohol use, anti-anxiety agents, antihypertensive agents, diuretics, hypnotics, narcotics/opiates, tranquilizers, tricyclic antidepressants, anemias, arthritis, diarrhea, decreased lower extremity strength, difficulty with gait, faintness when extending neck, foot problems, hearing difficulties, impaired balance, impaired physical mobility, incontinence, neoplasms, neuropathy, orthostatic hypotension, post-operative conditions, postprandial blood sugar changes, presence of acute illness proprioceptive deficits, sleepnessless, urgency, vascular disease, visual difficulties
Define Nursing Diagnosis: Mobility: Physical, Impaired
A limitation in independent, purposeful physical movement of the body or of one or more extremities
Defining characteristics for Mobility: Physical, Impaired
decreased reaction time, difficulty turning, engages in substitutions for movement, exertional dyspnea, gait changes, jerky movements, limited ability to perform gross motor skills, limited ability to perform fine motor skills, limited range of motion, movement-induced tremor, postural instability, slowed movement, uncoordinated movements
Define Nursing Diagnosis: Oral mucous membrane, Impaired
Disruption of the lips and/or soft tissues of the oral cavity
Defining characteristics for Oral mucous membrane, Impaired
bleeding, cheilitis, coated tongue, desquamation, difficult speech, difficulty eating, difficulty swallowing, diminished taste, edema, enlarged tonsils, fissures, geographic tongue, gingival hyperplasia, gingival pallor, gingival recession, halitosis, hyperemia, macroplasia, mucosal denudation, mucosal pallor, nodules, oral discomfort, oral lesions, oral pain, oral ulcers, papules, pocketing deeper than 4mm, presence pathogens, purulent drainage, red or bluish masses, reports bad taste in mouth, smooth atrophic tongue, spongy patches, stomatitis, vesicles, white, curd-like exudates, white patches/plaques, xerostomia
Define Nursing Diagnosis: Self care deficit: bathing
Impaired ability to perform or complete bathing/hygiene activities for self
Defining characteristics for Self care deficit: bathing
inability to access bathroom, inability to dry body, inability to get bath supplies, inability to obtain water source, inability to regulate bath water, inability to wash body
Define Nursing Diagnosis: Self care deficit: dressing
Impaired ability to perform or complete dressing ad grooming activities for self
Defining characteristics for Self care deficit: dressing
inability to choose clothing, inability to put clothing on lower body, inability to maintain appearance at a satisfactory level, inability to pick up clothing, inability to put clothing on upper body, inability to put on shoes, inability to put on socks, inability to remove clothes, inability to remove shoes, inability to remove socks, inability to use assistive devices, inability to use zippers, inability to fasten clothing, impaired ability to obtain clothing, impaired ability to put on necessary items of clothing, impaired ability to put on shoes, impaired ability to put on socks, impaired ability to take off necessary items of clothing, impaired ability to take off shoes, impaired ability to take off socks
Define Nursing Diagnosis: Self care deficit: toileting
Impaired ability to perform or complete toileting activities for self.
Defining characteristics for Self care deficit: toileting
inability to carry out proper toilet hygiene, inability to flush toilet or commode, inability to get to toilet or commode, inability to manipulate clothing to toileting, inability to rise from toilet or commode, inability to sit on toilet or commode
Define Nursing Diagnosis: Skin integrity, Impaired
Altered epidermis and/or dermis
Defining characteristics for Skin integrity, Impaired
Destruction of skin layers, disruption of skin surface, invasion of body structures
Define Nursing Diagnosis: Skin integrity, risk for impaired
At risk for skin being adversely altered
Risk factors for Skin integrity, risk for impaired
External: chemical substance, excretions and/or secretions, extremes of age, humidity, hyperthermia, hypothermia, mechanical factors, moisture, physical immobilization, radiation. Internal: alterations in skin turgor, altered circulation, alter metabolic state, altered nutritional state, altered pigmentation, altered sensation, chronic disease, developmental factors, history of pressure ulcers, immunological deficit, medication, psychogenetic immunological factors, skeletal prominence, vascular disease
Define Nursing Diagnosis: Tissue Integrity, impaired
Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues
Defining characteristics for Tissue integrity, impaired
damaged tissue (cornea, mucous membrane, integumentary or subcutaneous tissue), destroyed tissue
