Observe the rate, depth, and character of the client's respirations. Show Rationale: Recommended textbook solutions
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database contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. evaluation to measure if goals in the planning step were met; a step in the nursing process implementation consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions. intervention A nursing intervention is "any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes". nursing care plan Written guidelines of nursing care that document specific nursing diagnoses for the client and goals, interventions, and projected outcomes. nursing diagnosis A nursing diagnosis is a statement of client health status that nurses can identify, prevent, or treat independently. Responces
nursing process a systematic, rational method of planning and providing individualized nursing care planning a deliberate, systematic phase of the nursing process that involves decision making and problem solving. priority setting the process of establishing a preferential sequence for addressing nursing diagnoses and interventions. problem (Diagnostic Label) The problem statement, or diagnostic label, describes the client's health problem or response for which nursing therapy is given. It describes the client's health status clearly and concisely in a few words. problem-solving Depending on the type of client problem, the nurse writes interventions for observation, prevention, treatment, and health promotion. nursing health history data about the client's current level of wellness - included a review of body systems, family and health history, sociocultural history, spiritual health, and mental and emotional reactions to illness Objective data also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled and are obtained by observation or physical examination. ~Example~ labs or temperature Subjective data also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person. For example: itching, pain, feelings of worry. Medical Diagnosis A medical diagnosis is made by a physician and refers to a condition that only a physician can treat. actual health care problems An actual nursing diagnosis is based on the presence of associated signs and symptoms. potential health care problems (high risk for....) Risk factors indicate that a problem is likely to develop unless nurses intervene. quality assurance refers to evaluation of the level of care provided in a health care agency, but it may be limited to the evaluation of the performance of one nurse or more broadly involve the evaluation of the quality of the care in an agency, or even in a country. rationale the evidence-based principle given as the reason for selecting a particular nursing intervention. priority status established in order of importance or urgency patient-centered goals in terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. outcome criteria Descriptions of specific patient behaviors or responses that demonstrate meeting of or achievement of goals related to each nursing diagnosis. These statements, like goals, should be verifiable, framed in behavioral terms, measurable, and time specific. Outcome criteria are considered to be specific, whereas goals are broad. projected outcomes Begin with "Patient will..." activities of daily living Behaviors related to personal care that typically include bathing, dressing, eating, toileting, getting in or out of a bed or a chair, and walking. dependent interventions activities carried out under the orders or supervision of a licensed physician or other health care provider authorized to write orders to nurses. Example~ Medical Doctor perscribes a patient a medication. independent interventions those activities that nurses are licensed to initiate on the basis of their knowledge and skills. Example~ home meal plan interdependent interventions also called collaborative interventions. Actions the nurse carries out in collaboration with other health team members, such as physical therapists, social workers, dietitians, pharmacists and primary care providers. preventive nursing action promote health and prevent illness to avoid the need for acute or rehabilitative health care protocol predeveloped to indicate the actions commonly required for a particular group of clients. standing order a written document about policies, rules, regulations, or orders regarding client care. audit refers to the examination or review of records. inspection The skill of observing the client in a deliberate, systematic manner palpation to examine by touch percussion tapping a part of the body for diagnostic purposes auscultation listening to sounds within the body (usually with a stethoscope) physical exam head to toe, skin color, hygiene, mental status, movement, posture What Is the Nursing Process? A systematic problem-solving process that guides all nursing actions What is the Purpose of the Nursing Process? To help the nurse provide goal-directed, client-centered care What are the Phases of the Nursing Process? Assessment Core Value 2: Holistic Caring Process Provide care that recognizes the totality of the human being using an integrated and comprehensive approach. A 'circular' process way of thinking. Holistic nurses focus on care interventions that promote healing, peace, comfort, and a subjective sense of well-being for the person. What is the " General Survey"? The overall impression of the client. * It begins at first contact and continues throughout the exam. First Impressions Nursing Process: Assessment Assessment is the systematic gathering of information related to the physical, Mental, Spiritual, Socioeconomic, and cultural status of an individual group, or community. Nursing Process: Assessment (cont'd) Assessment includes: Collecting data Using a systematic and ongoing process Categorizing data Recording data What is the difference between Medical assessments and Nursing Assessments? Medical Assessments focus on disease and pathology. Nursing Assessments focus on the client's responses to illness. Type of Nursing Assessments Initial Collecting Data Primary data: directly from the client Secondary data: from a family member or another person The Nursing interview Purposeful communication Relation to Other Steps Diagnosis Planning outcomes and interventions Relation to Other Steps (cont'd) Implementation Evaluation Basic Physical Assessment Techniques Inspection Organizing Data How do we organize data? Nursing Models Non-Nursing Models Organizing our Thinking Gordon's Functional Health Patterns *Describe common patterns of behavior that can be functional or dysfunctional *Model intended for nursing assessment. *Functional Health Pattern are major model concepts. Organizing Our Thinking: Gordon's Functional Health Patterns Sexuality-Reproductive Remember+ things can fall into more than one place of data Clinical Data Tool Example Knowledge Check Which action by the nurse may be a barrier to obtaining complete and reliable information from an interview with a client? a. Nothing that the client's body language indicates that he or she is fatigued. b. Maintaining eye contact with the client if it is not culturally inappropriate to do so. c. Carefully guiding the conversation so that important topics are discussed d. Asking the client directly, "Why are you not taking your insulin?" Validating Data- When to Validate Subjective/objective
data do not agree or make sense Knowledge Check When gathering admission assessment data, the nurse obtains a weight of 200 pounds. The client States, "I've never weighed that much!" The nurse should? a. Explain to the client how weight gain occurs. b. Check the calibration and re-weigh the client. c. Document the weight as 200 pounds. d. Instruct the nursing assistant to re-weigh the client in 2hrs. Documenting Data Document as soon as possible Reflecting on the Assessment -Are my data complete, accurate, validated? What is Diagnosing? Using critical thinking skills to identify
patterns in the data and draw conclusions about the client's health status Evolution of Nursing Diagnosis "The diagnosis and treatment of human response to actual or potential health problems." (ANA, 1980) Human responses to Health Problems -A health problem is any condition that requires intervention in order to promote wellness or to prevent or resolve disease/illness Types of Nursing Diagnosis Actual: An actual nursing diagnosis describes a clinical judgment that the nurse has validated because of the presence of a major defining characteristic. Risk: A risk nursing diagnosis describes a clinical judgment that an individual/ group is more vulnerable to develop the problem than others in the same or a similar situation because of risk factors. Possible Wellness: A wellness diagnosis is a clinical judgment about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness Analyzing Data -Identify significant data Prioritizing Problems Places problems in order of importance Maslow- Prioritization Organize and prioritize care to the framework of Maslow NANDA-I Nursing Diagnosis: Components Diagnostic label How to Choose a NANDA-I Label Identify the broad topic (or domain) that seems to fit the cue cluster Narrow your search (to the class or most likely labels) Use a nursing diagnosis handbook; compare definitions and defining characteristics of the diagnostic labels with your cue cluster How Nursing Diagnosis Relates to Outcomes and Interventions The problem suggests the goal. The etiology suggests interventions. What is Planning? Planning can be formal or informal " Formal Planning is a conscious, deliberate activity involving decision making, critical thinking, and creativity" (Wilkinson et al..., 2016) Informal planning: Making mental notes or plans
Why is a written nursing care plan important? Ensures care is complete Planning Client Goals/Outcomes Goals: Describe the changes in client health status you hope to achieve Nursing-sensitive outcomes: Those that can be influenced by nursing interventions Reflecting Critically About Expected Outcomes/Goals Is each expected outcome: Appropriate for the nursing diagnosis? Reflecting Critically About Expected Outcomes/Goals (cont'd) Is Each expected outcome: Stated in positive terms? What are Nursing Interventions? Purpose: to achieve client outcomes Process Used for Generating and Selecting Interventions 1. Review the nursing diagnosis Implementation Phase Doing, delegating, and documenting Documentation The final step of implementation Records the nursing activities and client's response Evaluation The final step of the nursing process * Evaluate Evaluating and Revising the Care Plan Relate outcome to interventions Draw conclusions about problem status Revise the care plan Checklist for Evaluating the Care Plan Review assessment
Common Errors of Evaluation Failing to evaluate systematically Activity and Exercise Functional Health Pattern Activity and Exercise Wellness Diagnosis One Part Statement Diagnostic label/ category "Readiness for Enhanced ________________" (e.g. Readiness for enhanced self-care management) A client has a desire to increase wellness in a particular area and the client is currently functioning effectively in a particular area. Two Part Statements "Risk" nursing diagnoses has two parts. The validation for a risk nursing diagnosis is the presence of risk factors. The risk factors are the second part (etiologies) ~Example~ Risk for impaired skin integrity related to immobility. Three Part Statements An actual nursing diagnosis consists of three parts: Diagnostic label/ category ~Example~ Impaired skin integrity related to immobility as evidenced by a 2cm wound on the left foot. Holistic Nurse Caring Process The nursing process and the standard of Practice for Holistic Nursing define what holistic nurses do: Assessment Diagnosis (pattern, problem, need, health, issue) Planning/ Outcomes Identification Implementation Evaluation Holistic Assessment - The holistic nurse collects comprehensive data pertinent to the person's health and/ or the situation Nurse and client identify health patterns and prioritize health concerns. Includes physical, functional, psychological, mental emotional, cultural, spiritual, transpersonal, and energy field assessment of the whole person. Involves scientific and intuitive approaches (analytical and "gut feelings") Intuitive Thinking Collection and evaluation of information and patient data from an intuitive, nonverbal (right brain) mode. Emerges when the nurse is open and present to the patient's subtle clues. Allows a nurse to know something immediately without consciously using reason Intuitive Perception & Intuition Intuitive Perception: allows one to know something without consciously using reason. Intuition: the perceived knowing of things and events without the conscious use of rational processes; using all of the senses to receive information Clinical Intuition: "process by which we know something about a client that cannot be verbalized, or is verbalized poorly, or for which the source of the knowledge cannot be determined." Holistic Diagnosis - the holistic nurse analyzes assessment data to determine the diagnosis or issues expressed as actual or potential patterns, problems, needs, and/ or health issues. Identification of the patterns, needs &
challenges obtained from the assessment data to provide an understanding of the client's experience. Identification of client risk factors that influence health. The focus is on the client's goals to increase well-being and health Holistic Care Planning - Develops a plan with strategies and alternatives to attain expected outcomes. The holistic nurse creates a care plan that... Respects the client's experience and the uniqueness of each healing journey. uses both biomedical treatments and conventional care in conjunction with complementary/ integrative care and therapies. Holistic Outcomes Identification - Identifies expected outcomes for an individualized plan to the person and/or situation. The holistic nurse identifies outcomes... Based on the client's values and beliefs, preferences, age, spiritual practices, environment, ethical considerations, and or situations. Partners with the person to identify realistic goals based on the persons present and potential capabilities and quality of life. Holistic Implementation/ Intervention - The holistic nurse implements the identified plan in partnership with the person. The therapeutic use of self is one of the best ways a nurse can help/ intervene and promote healing for clients. Also includes: Holistic Evaluation In partnership with the client and others, the holistic nurse..... Evaluates if care is effective Notes changes in the health experience of the individual Realizes that outcomes are continuous and that frequent changes occur with illness and health. Monitors if the outcomes were successfully achieved. Reflective Practice Reflective practice is a mindful process of self-observation in the midst of an experience, as well as after an experience..... for the purpose of resolving values and practice contradictions, to gain new self-insight and empowerment, and to respond more congruently in future situations. Core Value 1: Holistic Philosophy, Theories, Ethics Theory of Integral Nursing A comprehensive way to organize multiple phenomena of human experience related to four perspectives of reality. Theory of Integral Nursing An integral worldview and approach that can help each nurse and student nurse increase her or his self-awareness, as well as awareness of how one's self-affects others-- the patient, family, colleagues, the workplace, and the community." Guiding Principles in Dossey's Theory of Integral Nursing Holistic- addressing all aspects of our lives incorporating experiences and relationships Evolutionary- to evolve our lives to higher levels of being Intentional- the capacity to attend, to choose, and act accordingly Person-centered- focus on unique characteristics of self and others Dynamic- Respect and concern for the vital movement and flow of our lives Two Views on the Nursing Process: Linear Process: Circular Process: ~Example~ A nurse might be assessing a patient while also interviewing the patient What is the rationale for using nursing process in planning care for clients?The following are the purposes of the nursing process: To identify the client's health status and actual or potential health care problems or needs (through assessment). To establish plans to meet the identified needs. To deliver specific nursing interventions to meet those needs.
What is the purpose of planning in nursing process?The planning stage is where goals and outcomes are formulated that directly impact patient care based on EDP guidelines. These patient-specific goals and the attainment of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting.
What are the advantages of using nursing process while providing care to a client?Helps to establish priorities of nursing actions for providing proper services to the patients. Helps to develop planned organized and individualised nursing care. Helps to encourage for innovative nursing care. Helps to provide for alternative nursing actions.
What is the purpose of the nursing process quizlet?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. The nursing process is cyclical.
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What is the rationale for using the nursing process in planning care for clients quizlet?
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