Nursing Process

What are some examples of critical thinking in the PLANNING stage of the nursing process?

Forming valid generalizations; Transferring knowledge from one situation to another; Developing evaluative criteria; Hypothesizing; Making interdisciplinary connections; Prioritizing client problems; Generalizing principles from other sciences

4 Types of Assessment:

Initial assessment; Problem-focused assessment; Emergency assessment; Time-lapsed reassessment

Diagnosing: activities

Interpret and analyze data: Compare data against standards; Cluster or group data (generate tentative hypotheses); Identify gaps and inconsistencies. *Determine client strenghts, risks, diagnoses and problems *Formulate nursing diagnoses and collaborative problem statements *Document nursing diagnoses on the care plan

Using the Senses to Observe Client Data: Vision

Overall appearance (e.g., body size, general weight, posture, grooming); signs of distress or discomfort; facial and body gestures; skin color and lesions; abnormalities of movement; nonverbal demeanor (e.g., signs of anger or anxiety); religious or cultural artifacts (e.g., books, icons, candles, beads)

Planning

Prioritize problems/diagnoses; Formulate goals/desired outcomes; Select Nursing Interventions; Write nursing interventions

Planning: activities

Reassess the client to update the database. Determine the nurse's need for assistance. Perform planned nursing interventions. Communicate what nursing actions were implemented. *Document care and client responses to care. *Give verbal reports as necessary

Implementing

Reassess the client; Determine the nurse's need for assistance; Implement the nursing interventions; Supervise delegated care; Document nursing activities

Planning: activities

Set priorities and goals/outcomes in collaboration with client. Write goals/desired outcomes. Select nursing strategies/interventions. Consult other health professionals. Write nursing interventions and nursing care plan. Communicate care plan to relevant health care providers.

Using the Senses to Observe Client Data: Touch

Skin temperature and moisture; muscle strength (e.g., hand grip); pulse rate, rhythm, and volume; palpatory lesions (e.g., lumps, masses, nodules)

Emergency Assessment

Time Period: During any physiologic or psychologic crisis of the client; Purpose: To identify life-threatening problems. To identify new or overlooked problems; Example: Rapid assessment of a person's airway, breathing status, and circulation during a cardiac arrest. Assessment of suicidal tendencies or potential for violence.

Problem-focused Assessment

Time Period: Ongoing process integrated with nursing care; Purpose: To determine the status of a specific problem identified in an earlier assessment; Example: Hourly assessment of client's fluid intake and urinary output in an ICU. Assessment of client's ability to perform self-care while assisting a client to bathe.

Initial Assessment

Time Period: Performed within specified time after admission to a health care agency; Purpose: To establish a complete database for problem identification, reference, and future comparison; Example: Nursing admission assessment

Time-lapsed Reassessment

Time Period: Several months after initial assessment; Purpose: To compare the client's current status to baseline data previously obtained; Example: Reassessment of a client's functional health patterns in a home care or outpatient setting or, in a hospital, at shift change.

Planning: purpose

To assist the client to meet desired goals/outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functioning

Evaluating: purpose

To determine whether to continue, modify, or terminate the plan of care

Planning: purpose

To develop an individualized care plan that specifies client goals/desired outcomes, and related nursing interventions.

Assessing: purpose

To establish a database about the client's response to health concerns or illness and the ability to manage health care needs

Diagnosing: purpose

To identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions. To develop a list of nursing and collaborative problems.

What is the nursing process?

a systematic, rational method of planning and providing nursing care.

Open ended questions

associated with the nondirective interview, invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings. Invites answers longer than one or two words. This type of question may begin with "what" or "how" (caution: "what do you want to do?" can bring a short answer like, "nothing" and would be a closed ended question)

I'm also not doing the box on p.182 re:

subjective and objective data

What is the purpose of the nursing process?

to identify a client's health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.

Closed questions

used in the directive interview, are restrictive and generally require only yes or no or short factual answers giving specific information. This type of question often begins with "when," "where," who," what," and "do (did, does)," or "is (are, was)."

Personal Space Variables

Accepted distance between individuals in converstaion varies with ethnicity. It is about 8-12 inches in Arab countries, 18 inches in the U.S., 24 inches in Britain, and 36 inches in Japan; Men of all cultures usually require more space than women; Anxiety increases the need for space; Direct eye contact increases the need for space; Physical contact is used only if it has a therapeutic purpose. Touch, even a simple hand on the shoulder, can be misinterpreted - especially between persons of opposite gender.

Diagnosing

Analyze data; Identify health problems, risks, and strengths; Formulate diagnostic statements

Diagnosing: description

Analyzing and synthesizing data

What are the 5 steps of the nursing process?

Assessment; Diagnosis; Planning; Implimenting; Evaluating

Using the Senses to Observe Client Data: Smell

Body or breath odors

Implementing: description

Carrying out (or delegating) and documenting the planned nursing interventions

Evaluating: activities

Collaborate with client and collect data related to desired outcomes. Judge whether goals/outcomes have been achieved. Relate nursing actions to client outcomes. Make decisions about problem status. Review and modify the care plan as indicated or terminate nursing care. Document achievement of outcomes and modification of the care plan.

Evaluating

Collect data related to outcomes; Compare data with outcomes; Relate nursing actions to client goals/outcomes; Draw conclusions about problem status; Continue, modify, or terminate the client's care plan

Assessing

Collect data; Organize data; Validate data; Document data

What are some examples of critical thinking in the DIAGNOSING stage of the nursing process?

Finding patterns and relationships among cues; Making inferences; Suspending judgment when lacking data; Stating the problem; Examining assumptions; Comparing patterns with norms; Identifying factors contributing to the problem

Planning: description

Determining how to prevent, reduce, or resolve the identified priority client problems; how to support client strengths; and how to implement nursing interventions in an organized, individualized, and goal-directed manner

Assessing: activities

Establish a database: Obtain a nursing health history; Conduct a physical assessment; Review client records; Review nursing literature; Consult support persons; Consult health professionals. *update data *Organize data *Validate data *Communicate/document data

Practice guidelines for Communication During an Interview

Listen attentively, using all your senses, and speak slowly and clearly; Use language the client understands, and clarify points that are not understood; Ask only one quesiton at a time. Multiple questions limit the client to one choice and may confuse the client; Acknowledge the client's right to look at things the way they appear to him or her and not the way they appear to the nurse or someone else; Do not impose your own vlaues on the client; Avoid using personal examples, such as saying, "If I were you ...."; Nonverbally convey respect, concern, interest, and acceptance; Be aware of the client's and your own body language; Be conscious of teh client's and your own voice inflection, tone, and affect; Sit down to talk with the client (be at an even level); Use and accept silence to help the client search for more thoughts or to organize them; Use eye contact and be calm, unhurried, and sympathetic

Using the Senses to Observe Client Data: Hearing

Lung and heart sounds; bowel sounds; ability to communicate; language spoken; ability to initiate conversation; ability to respond when spoken to; orientation to time, person, and place; thoughts and feeling about self, others, and health status

Evaluating: description

Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement.

Assessing: description

collecting, organizing, validating, and documenting client data

I did not do the boxes on the various

developmental theories such as Orem and Roy on p190

I didn't do p. 181 on the Components of a Nursing Health History because

didn't she say we weren't going to do it this way???

What happens if a client "falls off the track?"

if goals are not achieved (falling off the track), the cycle continues with reassessment, or the plan of care may be modified.

The nursing process is cyclical. What does this mean?

its components follow a logical sequence, but more than one component may be involved at one time.

What are some examples of critical thinking in the ASSESSMENT stage of the nursing process?

making reliable observations; Distinguishing relevant from irrelevant data; Distinguishing important from unimportant data; Validating data; Organizing data; Categorizing data according to a framework; Recognizing assumptions; Identifying gaps in the data