x 104, 1, The Nursing Process Flashcards
ANA stated in 2003
”..nurses are responsible for a unique dimension of healthcare…”
Elements of Prof Nursing
- provide caring relationship that fosters health and healing
- attn to range of human experiences and responses to health/illness within physical and social env
- use objective data w knowledge gained from patient
- Application of scientific knowledge to process of Dx and Tx thru use of judgement and critical thinking
- advancement of prof nursing knowledge through PD
- influence of social and public policy to promote social justice
WHen was the Nursing Process legitimized?
1973 when ANA Congress for Nursing Practice developed Standards of Practice to guide nursing performance
What year was Dx added to nursing process?
1974
Assessment, Dx, Planning, Implementation, Eval
The Nursing Process steps
ADPIE
- Assessment
- Dx
- Outcome ID and Planning
- Implementation
- Evaluation
What is the purpose of the nursing process
to provide a framework for nursing care of the patient in any envt.
Characteristics of the Nursing Process
- universally applicable
- systematic
- cyclical and dynamic
- patient centered, interpersonal, collab
- goal oriented
- problem solving process
Trend in Nursing Process
- toward standardization and computerization
- computer driven data bases allow nurses to plan and document
- critical pathways target desired outcome
Assessment
ANA Standard 1
- collection of pt centered data to be used as basis for identifying pt needs.
- ongoing process
Assessment Data
Data Collection:
-interview, observe, health hist, phys exam, ss, labs, reports. Subjective vs Objective
- Variations of data: physiological variations among populations
- Variation of approaches: style of convo, persona space, culture, age, energy level, cognition, phys state.
Common Assessment problems
- using inappropriate or inadequate assessment tools
- omitting data
- failure to update the initial assessment
Diagnosis
ANA Standard 2
-ID and prioritization of pt problems based on analysis of a comprehensive assessment and labeled as nursing dx.
Purpose of Dx
- to analyze/synthesize data to ID patients strengths and weaknesses
- make nursing judgement that ids patients response to health probs that fall within the scope of nursing practice.
Dx: Data Cluster
- group of patient data or cues that point to existence of health problem
- nursing dx should be derived from clusters of significant data rather than from a single cue.
Dx: Standards
- be familiar w other standards used in data analysis
- i.e. BP, norm values for pt’s age, race, illness category
- pts own normal range is important standard.
Types of Dx
- Actual: prob current for pt.
- Risk: pt has no ss but is likely to develop
- Possible: added data needed to determine if problem exists or can rule out
- Wellness: desire for increased wellness
- Syndrome: represent situation of event.
Components of Nursing Dx statement
- Nursing Dx
- Etiology
- Defining characteristics
(Nursing Dx) related to (Etiology) as evidenced by (defining characteristics)
Nursing Dx
- Nanda-I approved
- identified by its definition, defining characteristics and risk factors
- Categorizes patient problem from clustered assessment data or cues
Etiology
- factors that cause the health problem
- connected to nursing dx w term “related to”
- nursing care directed toward etiology may alleviate the patient problem
Defining Characteristics
- supports identified health problem or nursing dx.
- Linked to etiology with term “as evidenced by”
Revising Nursing Dx
modified as new or additional assessment data becomes available or patient condition changes.
Differentiate Nursing Dx from Medical Dx
Nursing Dx identify pt response to actual or potential health prob
Med Dx identifies disease w associated pathology
Guideline for writing Nurse Dx
- Nursing Dx (not Med)
- use critical thinking
- Prioritize nursing Dx (hi, med, lo)
Maslow’s Hierarchy of Needs
- Physiological (food, h20, shelter, clothing, rest)
- Safety (security, fam, society)
- Love/Belonging (give/receive love, friendship, intimate)
- Esteem (unique, self respect, general estem from others)
- Self Actualization (realize full potential, purpose, meaning, creativity, morality, spontaneity)
Outcomes ID & Planning
- Standard 3 and 4
- ID of expected outcomes
- patient centered plan address actual and potential health prob.
- use established nurse standards and protocols and evidence based findings
- measurable patient centered outcomes
The Nurse Practice Act
guidelines for legal standards of practice
American Nurses Assoc Code for Nurses
provides ethical standards for professional practice
American Nurses Assoc Code of Ethics
state that the nurse provides services with respect for human dignity and uniqueness of client, unrestricted by considerations for social or economic status, personal attributes, or the nature of the health problems.
Nursing Care Plan Types
- Informal: plan of action in the nurse’s mind
- Standardized: nursing care for clients with common needs
- Individualized: meet unique needs of client
Nursing Care Plans
- outlines care to assist patients in reaching goal
- BEGINS at Admissions
- Inc routine care for basic needs
- address nurse dx and collab problems
- specifies nursing responsibilities to execute med plan.
Implementation
- performing/delegating previously planned interventions.
- estab collab relationship w patient in order to carry out plan of care.
Implementation: Apply concepts from Nursing INtervention Classification (NIC) project when appropriate
- reduce contrib factors
- prevent problem
- address actual health probs
- collect data
- educate
Evaluate
Standard 6 of ANA (Amer Nurses Assoc)
- where expected outcomes achieved
- revise plan of care based on new data
Document/Reporting
- complete accurate written record of patient’s health status
- oral reporting of patient status
Formats for Nursing Progress Notes
- Electronic entry
- Narrative
- SOAPIER
- PIE
- Fous Charting
- POMR
- FACT system
- Charting by exception
Form for Nursing Prog Notes: Narrative
descriptive record of client data written in sentences and paragraphs
Form for Nursing Prog Notes: SOAPIER
- Subjective
- Objective
- Assessment
- Planning
- Implementing
- Evaluating
- Reassessing
Form for Nursing Prog Notes: PIE
- Problems
- Interventions
- Evaltuation
Form for Nursing Prog Notes: Focus Charting
use keywords to describe what is happening to client. Focus may be pt strength, prob or need.
Narrative portion uses DAR Format )Data, Action, Response
Form for Nursing Prog Notes: POMR
Problem Oriented Medical Record
Form for Nursing Prog Notes: FACT System
- Flow Sheet
- Assessment
- Concise
- Timely entries
Form for Nursing Prog Notes: Charting by exception
only significant findings or exceptions to norms are recorded
Forms for documenting care:
- DIscharge Summary-
- MAR (medication administration record)
- Admission (data) forms
- Flow sheets and graphic records
- Check lists
- Intake and output records
- Kardex or patient care summary
- Occurrence report
Oral Reporting
- Concise, pertinent, comprehensive
- CUBAN: Confidential, Uninterrupted, Brief, Accurate, Named
- Standard report formats: SBAR (situation, background, action, recomm), PACE forms
Phone Orders
- read back to MD
- record as verbal or phone order
- get sig within 24 hrs
Child Stages of Growth
FIRST
- baby brain develops.
- sensory/motor skills dev head down
Child Stages of Growth
SECOND
Dev proximo-distally (from far and midline to periphery)
- Torso before arms/legs
- hands, feet, finger, toes
Child Stages of Growth
THIRD
gross motor skill to fine
- Gross: walking, jumping, riding bike
- Fine: eating, coloring, buttoning shirt
T. Barry Brazelton
creates Model of Child Development
-touch points (periods during first 3 yrs of life, where child growth spurts result in pronounced disruption in family)
Touchpoints
periods during yr 1-3 where growth spurts disrupt family. Just
T. Barry Brazelton
Freud Development States
- Oral (—–> 1 yr) oral curiosity, suks, fist in mouth
- Anal (1-3): control eliminaion, control of boundaries
- Phallic (3-6): Sexual difference discovered
- Latency (6-12): focus on other aspects of growth/learning, hand w same gender friends
- Genital (12-18): puberty, sexuality ad relationships focus
Erik Erikson
7 Stages of Development
focus on influence of social interaction
- Trust vs Mistrust (–> 1yr): establish who is safe
- Autonomy vs Shame/Doubt (1-3) balance of independence and self sufficiency
- Initiative vs Guilt (3-6): dev resourcefulness to achieve and learn new things without receiving self-reproach. try new ideas. if ignored, may feel guilt or lack of resourcefulness
- Industry v Inferiority (6-12): sense of confidence
- Identity vs Role Confusion (12-18) clear sense of self
Types of child restraints
- Elbow restraints
- Hand restraints
- Mummy restraints
- ChloralHydrate
Chloral Hydrate
aka ‘date rape drug’
- sedative: 25mg/kg/day up to 500mg
- Hypnotic: 50mg/kg/day up to 1 g per single dose
- admin 1 hr before sx
- Peak: 1-3hrs
- Duration: 4-8hrs
- monitor dizziness, confusion, delirium
