Professional The Nursing Process Topics: – Flashcards

Recording body temperature two hours after administering antipyretic medication. Asking the patient about hygiene and sanitation in the patient's community. Identifying the signs of respiratory distress in a hospitalized patient. The nurse is responsible for collecting comprehensive data about the patient's health. The nurse records the body temperature after 2 hours to assess the effectiveness of the antipyretic medication. The nurse also asks the patient about the hygiene of the surrounding environment to assess the risk of acquiring infections caused by unhygienic surroundings. Nursing assessment also includes identifying the signs of a particular condition. Teaching a patient about the lifestyle changes required to reduce risks of ischemic heart disease is an example of the nursing process of implementation, not assessment. Asking the patient to demonstrate a technique after teaching it forms a part of the evaluation process, not the assessment process.

Pacing, Patient getting lost easily and getting up frequently

Independent nursing interventions pertain to activities of daily living, health education and promotion, and counseling. They also include activities such as repositioning a patient to relieve pain. Administration of analgesics and starting an intravenous infusion require an order from a healthcare provider.

While interviewing the patient, the nurse should not sit straight in the chair because it affects awareness, attention, and immediacy. Therefore, the nurse should lean forward while taking the interview. Good eye-to-eye contact is a signal of readiness to initiate interaction with the patient. Therefore, the nurse should maintain good eye contact with the patient. Giving more time for the patient to answer the questions will help the patient to understand the situation and respond accordingly. Nodding the head is an important social function, because it ensures interaction between the nurse and patient.

2 Wheezing in left lung bases 3 Respiration 20 breaths/minute 5 Shortness of breath with ambulation A data cluster is a set of signs or symptoms gathered during assessment and grouped together in a logical way. Respiratory rate, lung sounds, and shortness of breath are respiratory assessment findings that may be grouped together to manage a respiratory problem. Weakness and dysuria aren't directly related to respiratory issues.

A medical diagnosis is the identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history, and the results of diagnostic tests. Osteoarthritis and diabetes mellitus are medical diagnoses, because these can be diagnosed by a healthcare provider through diagnostic tests and medical history. Medical diagnoses are based on the results of diagnostic tests. A primary healthcare provider is licensed to describe medical diagnoses and treat diseases. Acute pain is a nursing diagnosis. It can be easily identified by observing a patient's signs and symptoms and does not require any specific diagnostic test. A medical diagnosis does not include a clinical judgment about an individual and his or her family. p. 225

PES is a three-part nursing diagnosis format. It includes the diagnostic label, etiological statement, and symptoms or defining characteristics. The P stands for problem, the E stands for etiology or related factors, and the S stands for symptoms or defining characteristics. The S does not stand for situation, sensitivity, or separation of data.

The nursing profession is accountable for the type and quality of care delivered to patients, so nurses should prepare by acquiring and updating knowledge, improving competencies, and acquiring technical skills. Avoiding documentation may generate more complications, such as legal issues. Nurses are given autonomy for various nursing practices, so they should be dependent only in aspects of care beyond their scope of practice.

The nurse is delivering care to the patient; therefore the standard practiced by the nurse is implementation. Assessment is the process of collecting data related to the health and illness of the patient. Nursing diagnosis involves analyzing the assessed data. Evaluation refers to determining the effectiveness of the implemented patient care in meeting the patient goals.

The patient has been put on a potentially toxic drug. Because the patient is elderly, the nurse should act as an advocate and take measures to protect the patient's rights. Therefore, the nurse may provide information that will help the patient decide whether to take the treatment. The nurse should not give the drug in a low dose, because that may not serve the purpose of administering it. The nurse should obey the instructions by the health care providers only after ensuring that the patient's concerns are addressed. At times, in order to protect human rights, the nurse needs to speak out against policies.

Assessment and Evaluation

Advocate

Planning is the third step of the nursing process. It involves setting priorities, identifying expected outcomes, prescribing nursing interventions, and identifying patient-centered goals. Planning requires critical thinking applied through deliberate decision making and problem solving. Collecting the history of the patient is an activity of the assessment phase. Implementing the care plan is an activity of the implementation phase of the nursing process.

Severe pain

1 Cough and shortness of breath 3 Dyspnea or difficulty in breathing 4 Problems caused by smoking

1 Nursing diagnoses 4 Specific nursing interventions 5 Goals and expected outcomes Generally, a nursing care plan includes nursing diagnoses, goals and expected outcomes, specific nursing interventions, and a section for evaluation findings so that any nurse can quickly identify a client's clinical needs and situation. Illness management, diagnosis, and treatment are not part of the nursing care plan.

During walking rounds, the nurse talks about the problem the patient care technicians created by not assisting the patient to ambulate. Creating a culture of blame does not support questioning, which is needed for good hand-off communication. Reviewing how to use the PCA with the patient is patient centered and thus appropriate; referring to the electronic care plan ensures that essential information is included, and administering the patient's pain medication before the report allows the nurse to be organized and uninterrupted during rounds.

Advocate; The nurse provides additional information and helps the patient decide whether to accept the treatment. Here, the nurse is acting as the patient's advocate, protecting human and legal rights and providing assistance in asserting these rights when needed. If the nurse explains concepts and facts about health, describes the reason for routine care activities, and demonstrates procedures such as self-care activities, the nurse is playing the role of an educator. As a caregiver, the nurse helps the patient and family set goals and assists them with meeting these goals using minimal financial cost, time, and energy. As a communicator, the nurse directly communicates strengths or weaknesses to the patient and the patient's family to give comfort and emotional support.

Discussing condition with patient Ethical care involves a discussion of the healthcare situation with the patient, the family, and other healthcare providers. To provide ethical care to the patient, it is most important to discuss the healthcare needs of the patient and then formulate a care plan. Administering morphine, assessing for signs of organ failure, and referring for a diagnostic procedure do not indicate delivery of ethical care. Every intervention for the patient will be first explained to the patient. Administering morphine for pain relief is appropriate to relieve pain. Assessing the patient for any signs of organ failure is required for identifying the interventions required to treat the complications. Referring the patient for appropriate diagnostic interventions is required for identifying the problems of the patient that need interventions.

The primary role of the nurse is to manage the disease and symptoms, but as a caregiver, the nurse may deal with other issues, too. The nurse should motivate the patient and the family members to set goals and achieve them. The nurse should take steps to restore the patient's spiritual, emotional, and social well-being. The nurse cannot provide financial aid but can guide the patient to various assistive associations. The nurse may inquire about the patient's personal and family problems to evaluate and help sort out issues.

A nursing-sensitive patient outcome is a measurable state, behavior, or perception of a patient, family, or community. The body temperature remaining at 98.6° F is an objectively measured change in the patient's status. The patient maintaining better eye contact during conversations is an observable outcome. Oxygen saturation can be measured and therefore is a nursing-sensitive patient outcome. The patient self-administering an injection and demonstrating infection control measures are two different behaviors. A correct patient outcome should be a singular action either to administer or to demonstrate. "The patient will appear less anxious" is not correct because there is no specific behavior that is observable.

Dependent nursing interventions are the actions that require the prescription from the healthcare provider or another healthcare professional. Inserting a Foley catheter, dressing a surgical incision wound, and administering an intravenous drug require consent from the primary healthcare provider. Monitoring blood pressure and teaching deep breathing exercises do not require the consent of the healthcare provider. These actions are referred to as independent nursing interventions.

Evidence-Based Practice refers to incorporating better quality interventions based on research. Referring to articles and systematic reviews to determine optimal care for a patient is an example of Evidence-Based Practice. Patient-Centered Care refers to providing care with respect to patients' needs, values, and preferences. Teamwork and Collaboration refers to work with a health care team to achieve the best quality of patient care. Safety refers to performing interventions that minimize risks.

Dependent nursing interventions require the primary healthcare provider's response to treat a medical diagnosis. Primary intervention is not a category of nursing intervention. Interdependent intervention requires the combined knowledge, skills, and expertise of multiple healthcare professionals. Independent nursing interventions do not require the primary healthcare provider's response.

There are three levels of the nursing interventions classification model. These levels are classes, domains, and interventions. Domains are the highest level of the model. At the highest level, domains use broad terms to organize the more specific classes and interventions. Classes offer useful clinical categories the nurse can refer to while selecting interventions. The third level of the model involves individual interventions. It is defined as any treatment based on clinical judgment and knowledge that the nurse performs for achieving the patient outcomes. Patient outcomes are the desired changes in the patient once an intervention is performed. The prior level and the lower level are not levels of the nursing interventions classification model.

The nurse caring for multiple patients at a time should understand that all patients are equally important. All should receive quality care, so they leave the health care setting with a positive image of nursing. Time management and a compassionate approach are keys to achieving these goals. However, the nurse should not cut down contact time with each patient; rather, the nurse should optimize contact time so all can be cared for and should deliver care in an organized manner, rather than in a hurried or rushed manner.

3 "NANDA-I diagnoses do not comprise evidence-based diagnoses." 5 "NANDA-I diagnoses are refined by the primary health care provider on a regular basis.

Expert nurse; According to Benner, the expert nurse has specialized skills and is capable of identifying both patient-centered problems and problems related to the health care system. The expert nurse passes through five levels of proficiency when acquiring or developing these skills. The proficient nurse perceives the clinical situation as a whole, is able to assess an entire situation, and readily transfers knowledge gained from multiple previous experiences. The competent nurse is able to anticipate nursing care and establish long-range goals. The advanced beginner nurse has some level of observational experience with the situation and is able to identify meaningful aspects or principles of nursing care.

There are three types of nursing diagnoses: risk diagnoses, problem-focused diagnoses, and health promotion diagnoses. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A problem-focused diagnosis describes a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Acute diagnoses and chronic diagnoses are not considered types of nursing diagnoses according to NANDA-I.

Assessment

Genomics describes the study of all the genes in an individual and the interactions of these genes with one another and with that individual's environment. Genomic information allows health care providers to determine how genomic changes contribute to patient conditions and influence treatment decisions.

Accurately interpreting and using reliable cues are ways to prevent errors in interpretation while making the nursing diagnosis. The nurse should also consider the influence of culture or developmental stage on the patient's health when formulating a nursing diagnosis. Failure to consider conflicting cues and using an insufficient number of cues may lead to misinterpretation and can lead to errors.

Infection risk is an example of a nursing diagnosis. A respiratory rate of 24 breaths per minute is an example of patient outcomes. Oxygen therapy is an example of a nursing intervention. These are acceptable components of a comprehensive nursing care plan. A healthcare provider's orders and diagnostic studies are part of the medical record, and only medical interventions are included.

Nurse practitioners and certified clinical nurse specialists encompass the role and preparation of the advanced practice registered nurse. According to the American Nurses Association standards of practice, prescriptive authority may be granted to these nurses.

The nursing diagnosis improves the selection of nursing interventions by nurses in all practice settings, not specific settings. The nursing diagnosis essentially helps the nurse identify patient health problems. Nursing diagnoses offer an approach to ensure comprehensive nursing assessment. Contributions from research build on the evidence for use of nursing diagnoses in identification of patients' health care problems.

There are seven guidelines that the nurse should keep in mind while writing goals and expected outcomes. They are patient-centered goals or outcomes, a singular goal or outcome, observable, measurable, time-limited, mutual factors, and realistic. Observable changes occur in physiological findings and in the patient's knowledge, perceptions, and behavior. The nurse observes outcomes by directly asking patients about their conditions or using assessment skills. The goals and outcomes should be measurable against a set standard. They should also be patient centered, reflecting the patient's behaviors and responses expected because of a nursing intervention. The goals and outcomes should not be health care provider-centered and there should be a time limit set for ascertaining progressive steps in patient care.

Nursing is an art and a science. The practice of nursing incorporates elements including clinical practice, education, research, management, and administration, all of which directly or indirectly have prominence in providing safe, patient-centered health care. Helping a patient achieve the goals of the therapy and educating a patient are steps towards the mission. Interpreting clinical situations and making decisions that benefit patients are integral to nursing. Nursing practice involves collaborative care of individuals of all ages, families, groups, and communities, sick or well. Nursing practice incorporates ethical and social values with the knowledge of behavioral, biological, and physiological sciences.

Mary Adelaide Nutting was instrumental in the affiliation of nursing education with universities and became the first professor of nursing at Columbia University Teachers College in 1906. Maitland Stewart founded the Frontier Nursing Service, which provided the first organized midwifery service in the United States. Lillian Wald founded the Henry Street Settlement in New York City and is considered the founder of community, or public health, nursing. Clara Barton was a Civil War nurse who used her experience on the battlefield to found the American Red Cross.

The nursing goal is that the patient understands the postoperative risks. The outcomes are achieved if the patient identifies signs and symptoms of wound infection and explains signs of urinary obstruction. It is important for the patient to understand the importance of a low-fat diet, but it may be difficult to measure the patient's level of understanding. It is important for the patient to understand the importance of exercise; however, it is not a measurable outcome. Measurable outcomes can be directly observed.

The objective of the American Nurses Association (ANA) is to promote national associations of nurses, improve standards of nursing practice, seek a higher status for nurses, and provide an international power base for nurses. ANA is a part of International Council of Nurses (ICN). It lobbies at the federal level about practice-related issues. ANA successfully lobbied state legislatures to restrict the length of overtime for individual nurses. ANA is not involved in nursing education; the National League for Nursing (NLN) handles education. The Robert Wood Johnson Foundation sponsored the Quality and Safety Education for Nurses (QSEN) initiative to respond to reports about safety and quality patient care.

There are seven guidelines for writing goals and expected outcomes. These guidelines are helpful for achieving the desired goals. The goals and outcomes will be observable, time-limited, and patient-centered. The guidelines are not based on priority. Outcomes will be measurable to determine the effectiveness of the intervention.

The standard formal nursing diagnostic statements of the North American Nursing Diagnosis Association-International (NANDA-I) promotes the creation of practice guidelines that reflect the essence and science of nursing. They do not necessarily follow the traditional guidelines, which have been handed over through generations. The nursing diagnostic statements do not align the role of the nurse with other health care providers; rather, it distinguishes the nurse's role from that of other health care providers. Nursing diagnostic statements help nurses focus on the scope of nursing practice specifically, not medical practice as a whole. The nursing diagnostic statement essentially helps to foster the development of nursing knowledge. The nursing diagnostic statement allows nurses to communicate with each other in both written and electronic formats.

Collaborative interventions require the combined knowledge, skills, and expertise of multiple healthcare professionals. In this case, the interventions should include consulting with a physiotherapist, the home health department, and the unit discharge coordinator to implement the appropriate therapies for the patient. Preparing the patient for diagnostic tests and prescribing medication are physician-initiated interventions.