Nursing Process

sign

An objective finding perceived by the examiner ex. (fever, rash, etc.)

signs & symptoms are linked to the etiology by the phrase

"as evidenced by"

the etiology is linked to the problem with the phrase

"related to" ; The etiology cannot be related to a medical diagnosis.

prioritizing nursing dx ex 1

1 -airway 2- urinary 3- sexual 4- skin integrity

How does the nurse obtain assessment info?

1- initial (or admission assessment) 2- focused assessment 3- emergency assesment

what are frequent errors when writing nursing interventions

1-Failure to be precise or fully indicate the nursing action. 2-Failure to indicate frequency 3-Failure to indicate quantity 4-Failure to indicate method

3 helpful guides in prioritizing needs

1-Maslow 2- Pt preference what does the pt think is important 3-Anticipation or future problems

guidelines to remember when writing goals

1-client centered 2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic

Implementing Interventions: requires 3 skills

1-cognitive 2-personal 3-psychomotor

What are the characteristics of the nursing process?

1-framework for care to indiv, families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings

prioritizing nursing dx ex 2

1-gas exchange 2-hypothermia 3-knowledge defecit 4- infection

what are the 3 types of nursing interventions - provide examples

1-independent ex. positioning 2-dependent ex. med admin 3-collaborative or interdependent ex. OT

prioritizing nursing dx ex 3

1-pain 2-mobility 3- social isolation 4-self esteem

the implementation process takes into account 5 activities

1-reassessing 2-review/revise existing nursing dx & care plan 3-organizing resources & delivery of care 4-Anticipating/preventing any complications 5-Implementing interventions

what are the 4 types of NANDA-I dx

1. Actual diagnosis 2. Risk diagnosis 3. Health promotion diagnosis 4. Wellness diagnosis

the evaluation phase has 5 components

1. Identifying criteria and standards. 2. Collecting data to determine if the criteria or standards are met. 3. Interpreting and summarizing findings. 4. Documenting findings and any clinical judgment. 5. Terminating, continuing or revising the care plan.

what is the difference between a medical and nursing dx

A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or group response to an actual or potential problem.

how do you formulate an actual nursing dx; what does it consist of

A nursing diagnosis consists of 3 parts or what is referred to PES format: P= Problem E =Etiology S =Signs and Symptoms

What are the steps of the nursing process?

ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation

long term goal

An objective behavior or response you expect the client to achieve in a longer period of time possibly over several days, weeks, or months.

what is an expected outcome

An outcome is a measurable change in the client's status that you expect to occur related to the implemented care.

what are nursing interventions

Are actions or treatments based on knowledge or judgment that the nurse performs to meet the patient outcomes.

identify how you develop a nursing diagnosis

As you cluster data, you begin to consider various diagnoses that may relate to the client. You must remember that if certain defining characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.

health promotion dx

Clinical judgment of a person, family, or community desire to enhance their well being and readiness to implement health behaviors of a higher level. Ex. nutrition

focused assessment

Collects data about a problem that has already been identified. This type of assessment determines whether the problem still exists, or any changes.

wellness dx

Describes the human responses to levels of wellness in an individual, family or community that have readiness to enhance well being. Ex.Coping, readiness of enhanced related to successful cancer treatment.

what is the evaluation phase of the nursing process

Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has achieved the expected outcomes not if the nursing interventions were completed.

signs & symptoms

Identified as subjective and/or objective data that supports the problem. ‐ Identified by the nurse from the clustering of significant data including assessment findings.

subjective data

Information verbalized or stated by the client.

risk dx

Is defined by NANDA‐I , "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability" (NANDA, 2007). Ex. infection after surgery

Maslow

Maslow's Hierarchy of Needs a. physiological needs b. safety needs c. love and belonging needs d. self‐esteem needs e. self‐actualization needs

What is NANDA-I

North American Nursing Diagnosis Association International

Emergency assessment

Performed to identify a life‐threatening problem (choking, stab wound, heart attack).

actual dx

Represents a problem that has been validated by the presence of defining characteristics (signs and symptoms).

what is the implementation phase of the nursing process

This step begins after the care plan has been developed by the nurse. This is the step of the nursing process where the nurse performs the interventions as a means of achieving the goals.

collect the data then BLANK the data

VALIDATE ‐Confirm and verify the information. ‐ Keep it free from errors, bias, or misinterpretation.

Define the nursing process

a systematic problem solving approach toward providing individualized nursing care.

short term goal

an objective behavior or response you expect the client to achieve in a short period of time usually less than one week.

Data is 1,2,3

collected, validated, then clustered

Implementing Interventions: personal skills

communication ; therapeutic interactions

Implementing Interventions :cognitive skills

critical thinking ; good decisions

during the clustering of data what is used

critical thinking is used to analyze and synthesize the information that is collected. The data is then put into specific clusters that describe a specific client problem.

clustering of data often contains

defining characteristics which are specific assessment findings that support a nursing diagnosis.

what does the planning phase of the nursing process consist of

develop a plan of care.This is accomplished by developing client centered goals and expected outcomes. - use critical thinking to develop nursing interventions to resolve the client's problem and achieve the goals.

interventions can be BLANK or BLANK

direct (performed through interaction with the client) or indirect (without the client but on their behalf)

components of a correctly written goal

include expected outcomes or measurable criteria to evaluate the achievement of the goal.

what is the purpose of scientific rationale for student nurses

is the reason for choosing the particular intervention based on supportive evidence from textbooks, journals, and/or online nursing references (so we know why we are doing the task we are doing)

signs are

objective

How does the nurse obtain assessment info?

past medical hx - family hx - reason for admission - current meds - previous hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical assessment

2 sources of data

primary & 2ndary

Implementing Interventions ; psychomotor skills

proper performance and knowledge of skills

symptoms are

subjective

identify sources of data for obtaining information from the client

subjective & objective, primary & secondary, people, healthcare professionals, medical chart, test & lab results etc

what is the etiology

the cause ; Identifies the physiologic, psychological, sociologic, spiritual, or environmental factors assumed to be the cause of the problem or a contributing factor.

what is the purpose of the problem

to identify the health status or problem of the individual using the approved NANDA - I list. Ex.Pain, acute

nursing dx

‐ Clinical judgment in response to actual or potential health problems. ‐ Provides a basis for providing nursing care through various interventions to achieve outcomes. ‐ Changes possibly from day to day as the patient's response changes.

focused assessment questions

‐ What are your symptoms? ‐ When did they start? ‐ What activity were you doing ? ‐ What makes it better or worse? ‐ What are you doing to relieve the symptom?

medical dx

‐Identification of a disease condition based on specific findings such as diagnostic tests and procedures. ‐ Remains the same as long as the disease is present.

primary source of data

‐Information obtained from the patient (only)

identify how you develop a nursing diagnosis (what is first / next etc)

1. Complete thorough assessment of the patient. 2.Highlight or underline relevant symptoms (defining characteristics). 3. Make a list of symptoms. 4. Cluster and interpret the symptoms. 5. Analyze and interpret the symptoms. 6. Select a nursing diagnosis based on the definition found in the nursing diagnosis manual by Doenges, Moorhouse and Murr. 7. Remember to prioritize the identified problems.

symptom

Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in my stomach.")

define a goal

" a broad statement that describes the desired change in a client's condition or behavior."

how do you formulate a risk dx? what does a risk dx consist of?

consist of a problem and the etiology only - there are NO signs & sypmtoms because it hasn't happened yet

secondary sources of data

‐ Family members ‐ Significant others ‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from other healthcare professionals.

objective data

‐ Observable and measurable information. ‐ Remember to include your senses: smell, hearing, touch and sight.