Chapter 4 The Nursing Process and Pharmacology
health promotion or wellness nursing diagnosis statement is a one-part label initiated by the words
"readiness for enhanced..."
example of nursing interventions for patient with respiratory issues:
(date): cough, turn, deep breathe: 0800, 1000, 1200, 1400, 1600 (date): educate patient re: abdominal breathing, splinting abdomen, pursed-lip breathing, and assuming correct position to facilitate breathing
a systematic method of working with patients is used to identify four types of nursing diagnoses:
- actual - risk/high-risk - health promotion and wellness - syndrome
three types of nursing actions within the nursing process:
- dependent - interdependent - independent
risk-high-risk nursing diagnosis statements consist of two parts:
- diagnostic label from the NANDA-I approved list - risk factors that make the individual or group more susceptible to the development of the problem
with regard to relating the nursing process to the nursing gunctions associated with medications, assessment includes taking a drug history for three reasons:
- evaluate the patient's need for medication - obtain his or her current and past use of OTC medications, prescription medications, herbal products, and street drugs - identify problems related to drug therapy
the etiology and contributing factors are those clinical and personal situations that can cause the problem or influence its development, situations can be organized into five categories:
- pathophysiologic - treatment related - personal - environmental - maturational
the wording of an actual nursing diagnosis:
- patient problem summarizing the issue - contributing factors or cause, which may include ADLs or the medical diagnosis - defining characteristics
evaluation associated with drug therapy is an ongoing process that assess:
- patient's response to medications prescribed - observes for signs and symptoms of recurring illness - evaluates for therapeutic effects or the development of adverse effects of the medication - determines the patient's ability to receive patient education and to self-administer medications - notes the potential for compliance
the nurse draws on three sources to build the medication-related information base:
- primary source - subjective data - objective data
the planning stage of the nursing process encompasses four phases:
- priority setting - development of measurable goal and outcome statements - formulation of nursing interventions - formulation of anticipated therapeutic outcomes that can be used to evaluate the patient's status
the seven rights of drug administration:
- right patient - right drug - right dose - right route - right time - right indication - right documentation
application of data from scientific research to make clinical decisions about the care of individual patients
evidence-based practice
nursing diagnosis type; a clinical judgment about an individual, group, or community in transition from a specific level of wellness to a higher level of wellness
health promotion and wellness nursing diagnosis
nursing actions that are not prescribed by a healthcare provider that a nurse can provide by virtue of the education and licensure that he or she has obtained
independent actions
nursing actions that the nurse implements cooperatively with other members of the healthcare team for restoring or maintaining the patient's health
interdependent actions
LDH
lactate dehydrogenase
starts with an action word that is followed by the behavior or behaviors to be performed by the patient or the patient's family within a specific amount of time
measurable goal statement
designed to provide a standardized language for reporting and analyzing nursing care delivery that has been individualized for the patient
nursing classification systems
describe how specific actions, including time intervals, will be implemented for an individual patient
nursing orders
a comprehensive standardized classification system of patient outcomes that was developed to evaluate the effect of nursing interventions on patient care
nursing outcomes classification (NOC)
the foundation for the clinical practice of nursing; provides the framework for consistent nursing actions and involves the use of a problem-solving approach
nursing process
nursing diagnosis type; a clinical judgment that an individual, family, or community is more susceptible to the problem than others in the same or a similar situation - supported by risk factors that contribute to increased vulnerability
risk/high-risk nursing diagnosis
nursing diagnosis type; cluster actual or high-risk signs and symptoms that are predictive of certain circumstances or events - the causative or contributing actors for the diagnosis are contained in the diagnostic label
syndrome nursing diagnosis
priority ranking in preparation for health education may encompass several factors:
- the patient's concerns, belief system, and priorities - the urgency or time available for the learning to take place - a sequence that allows the patient to move from simple to more complex concepts - a review of the overall needs of the individual
a collaborative problem statement is worded as a potential complication, which is abbreviated as
PC (ex: "PC Hypokalemia)
nursing diagnosis type; based on human responses to health conditions and life processes that exist in an individual, family, or community - supported by defining characteristics that cluster in patterns of related cues or inferences
actual nursing diagnosis
ALT
alanine aminotransferase
AST
aspartate aminotransferase
BUN
blood urea nitrogen
when the nurse cannot legally order the definitive interventions required under the presenting circumstances, a _____________________ problem exists
collaborative
measures of care that are tracked to show how often hospitals and healthcare providers use the care recommendations identified by evidence-based practice standards for patients who are being treated for conditions such as heart attack, heart failure, and pneumonia or for patients who are undergoing surgery
core measures
actions performed by the nurse on the basis of healthcare provider's orders
dependent actions