The Nursing Process

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What are the 5 steps to the nursing process?
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1. Assessing 2. Diagnosing 3. Planning 4. Implementing 5. Evaluating
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Assessing
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– collect data – organize data – validate data – document data
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Diagnosing
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– Analyze data – Identify health problems, risks and strengths – Formulate diagnostic statements
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Planning
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– Prioritize problem/diagnoses – Formulate goals/desired outcomes – Select nursing interventions – Write nursing interventions
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Implementing
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– Reassess the client – Determine nurse’s need for assistance – Implement the nursing interventions – Supervise delegated care – Document nursing activities
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Evaluating
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– 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 clients care plan
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Characteristics of the nursing process
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– Cyclic and dynamic rather than static – Client centered: patient advocate * – Problem-solving and systems theory (systematic) * – Decision making – Interpersonal and collaborative – Universal applicability – Critical thinking skills – Components may overlap, but follow order: ASSESSMENT-DIAGNOSING-PLANNING-IMPLEMENTING-EVALUATING * – Joint function of nurse & patient *
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An essential concept related to understanding the nursing process is that it: A. is dynamic rather than static B. focuses on the role of the nurse C. is based on the patient’s medical problem D. is used by all allied health professionals
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A. is dynamic rather than static
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A nursing student is learning the application of the nursing process to client care. Why use the nursing process? A. Includes the disease the client has during treatment of care B. Helps other health professionals understand the plan of care C. Helps standardize care for all clients D. Describes client problems that nurses are licensed to treat
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D. Describes client problems that nurses are licensed to treat
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Guidelines for Writing Nursing Care Plans
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– Be specific – Tailor the plan to the client – Incorporate prevention and health maintenance – Include ongoing assessment – Include collaborative and coordination activities (other disciplines – PT) – Include discharge planning and home care needs (starts on admission***)
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Standardized Approaches to Care Planning
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– standing order – protocols – policies & procedures – standardized care plans
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Standing order
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Nurses have authority to carry out certain actions under certain circumstances (ie- hyoglycemia)
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Protocols
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Actions commonly required for particular group of clients (ie-epidural analgesia)
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Policies & procedures
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Govern handling of frequently occurring situations (ie-visiting policy) Ex. Giving morphine
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Standardized care plans
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– Pre-developed guides; what care the client can expect – Part of permanent medical record – Detailed interventions from standards of care of agency – Problem-goals/desired outcomes-nursing interventions-evaluation – May be individualized
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What is the primary goal of assessment?
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Collect & cluster (group) data
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Types of data in assessment
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– Subjective: client states …”phrase” – Objective: can be seen, heard, felt, smelled or measured
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Subjective data
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– Symptoms or covert data – Apparent only to the person affected – Can be described only by person affected – Patient QUOTE
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What does subjective data include?
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Includes: sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
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Objective Data
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– Signs or overt data – Detectable by an observer – Can be measured or tested against an accepted standard – Can be seen, heard, felt, or smelled
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How is objective data obtained?
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– Obtained through observation or physical examination
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Which of the following is an example of objective data? Client ate 50% of lunch. Client states, “I feel chilled.” Client states, “I need to go to the bathroom.” Client states,”I have no appetite.”
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Client ate 50% of lunch.
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Collecting Data
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– Gathering information about a client’s health status
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What must collecting data be?
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It must be both systematic and continuous
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What should collecting data include?
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Should include past history and current problem
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Who is the primary source of collecting data?
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– Client is usually primary source or comes from secondary source (all other sources of data) – Who is the best secondary source of data: depends on situation (i.e.- parent for young child, child for frail older adult, etc.) ?
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Way to “Cluster” or Group Data: Gordon’s Functional Health Patterns
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– Health-perception – health managment – Nutritional-metabolic – Elimination – Activity exercise – Sleep – Cognitive-perceptual – Self-perception – self-concept – Role-relationship – Sexuality-reproductive – coping-stress – value- belief
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Health-perception – health managment
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Perceived health & well-being; how health is managed
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Nutritional-metabolic
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Food & fluid consumption relative to metabolic need & nutrient supply
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Elimination
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Excretory function (bowel,bladder, skin)
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Activity-exercise
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Exercise, activity, leisure & recreation
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Sleep
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Sleep & relaxation
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Cognitive-perceptual
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Sensory-perceptual & cognitive patterns
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Self-perception- self-concept
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Self-conception/worth, comfort, body image, feeling state
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Role-relationship
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Role participation & relationships
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Sexuality-reproductive
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Satisfaction & dissatisfaction; reproductive patterns
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Coping-stress
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General coping pattern & stress tolerance
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Value-belief
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Values, beliefs (includes spiritual), & goals that guide choices ***
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A patient recently diagnosed with DM states, “I cope well with new challenges.” What is this an example of related to Gordon’s Functional Health Patterns? A. Activity-exercise B. Coping-stress C. Sleep D. Elimination
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B. Coping-stress
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Which of the following is best categorized as secondary subjective data? A. The nurse measures a weight loss of 10 lbs B. The nurse palpates abdominal swelling C. Client states severe pain when eating D. Spouse states that the client has lost all appetite
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D. Spouse states that the client has lost all appetite
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A 3-year old child has been admitted to the pediatric unit following emergency surgery. The parents state, “We are so worried.” In this situation, what resource would be the best source of data? A. Admitting physician B. Grandparent via phone call C. Parents D. Medical record from the child’s birth
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C. Parents
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Methods of Data Collection
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– Observing – Interviewing – Examining
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Observing
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Gathering data using the senses
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What is observing used to obtain?
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– Skin color (vision) – Body or breath odors (smell) – Lung or heart sounds (hearing) – Skin temperature (touch)
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Interviewing
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Planned communication or a conversation with a purpose
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What is interviewing used to obtain?
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*** Primary reason: collect data Give information – Identify problems of mutual concern – Evaluate change – Teach – “What questions do you have…” ** – Provide support – Provide counseling or therapy
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Directive
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– Nurse establishes purpose – Nurse controls the interview – Used to gather and give information when time is limited, e.g., in an emergency
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Nondirective
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– Rapport-building – Client controls the purpose, subject matter, and pacing – Combination of directive and nondirective approaches usually appropriate during the information-gathering interview
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Types of Questions
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– Closed – Open-ended
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Closed
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– Restrictive Yes/no Factual – Less effort and information from client
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What type of questions are closed?
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“What medications did you take?” “Are you having pain now?”
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Open-ended
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– Specify broad topic to discuss Invite longer answers – Get more information from client – Useful to change topics and elicit attitudes
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Types of open-ended questions
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“How would you describe…”
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Which of the following is an example of an open-ended question that the nurse may use in the interview process? A. “What medication did you take today?” B. “What surgeries have you had in the past?” C. “How have you been feeling lately?” D. “Are you a student at the local university?”
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C. “How have you been feeling lately?”
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During an initial interview the client makes this statement, “I don’t understand why I have to have surgery. I’m not really sick or in pain right now.” What is the best response? A. “I think that these are things that you should be asking your doctor.” B. “It is OK to be worried. Surgery is a big step.” C. “Have you had surgery before?” D. “What kind of questions do you have about your surgery?”
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D. “What kind of questions do you have about your surgery?”
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Ideal interview setting
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– Time – Place – Seating arrangement – Distance – Language
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Time
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– Client free of pain – Limited interruptions
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Place
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– Private – Comfortable environment – Limited distractions
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Seating Arrangement
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– Hospital – Office or clinic – Group
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Distance
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Comfortable
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Language
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– Use easily-understood terminology – Interpreter or translator * Use in order to receive accurate information!
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When is interviewing better and how far away should you stand?
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Better in the morning Should be about 3 feet away for personal space
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A client comes into the ED with a non-life threatening wound to the hand. The department is quite busy. What is the best way for the nurse to conduct the interview? A. Have the client wait until it is less busy since the wound is not too serious B. Make sure the client’s back is to the rest of the room C. Draw curtains around the client and nurse to provide as much privacy as possible D. Tell the client to wait where they are and fill out the paperwork
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C. Draw curtains around the client and nurse to provide as much privacy as possible
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When interviewing, which of the following should the nurse be most concerned about related to culturally responsive care? A. Seating arrangement B. Setting C. Lighting D. Personal space
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D. Personal space
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Examining
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(physical examination) – Systematic data-collection method – Uses observation and inspection, auscultation, palpation, and percussion – Vital signs, height and weight – Cephalocaudal approach – Screening examination
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What is the name of the head-to-toe approach that usually begins physical examination? A. Review of systems B. Cephalocaudal C. Caudal approach D. Screening examination
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B. Cephalocaudal
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Types of Assessments
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– Initial – Problem-focused – Emergency – Time-lapsed
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Initial Assessment
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– Performed within a specified time period – Establishes complete database
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Problem-Focused Assessment
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– Ongoing process integrated with care – Determines status of a specific problem
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Emergency Assessment
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– Performed during physiologic or psychologic crises – Identifies life-threatening problems – Identifies new or overlooked problems
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Time-lapsed Assessment
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– Occurs several months after initial – Compares current status to baseline
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Frameworks for Nursing Assessment
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– Nursing models framework – Wellness models – Nonnursing models
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What are some nursing models frameworks?
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– Gordon’s functional health pattern framework – Orem’s self-care model – Roy’s adaptation model
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Nonnursing models
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– Body systems model – Maslow’s Hierarchy of Needs – Developmental theories
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Validating Data: “Double-Checking”
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– Assessment complete – Objective and related subjective data agree – Was any data overlooked? – Avoiding jumping to conclusions
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Documenting
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– Record client data – Record factual manner not interpreting by nurse – Record subjective data with quotes in client’s own words
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The end result of data collection is which of the following? A. Identifying actual or potential health concerns B. Identifying the client’s response to care? C. Evaluating the plan of care D. Carrying out the plan of care
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A. Identifying actual or potential health concerns
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Diagnosing
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– Analyzing the data- what is significant? – Diagnosis is a statement or conclusion regarding the nature of a phenomenon
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What is the standard NANDA name for diagnosing?
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– Diagnostic labels are the standardized NANDA names
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What is the nursing diagnosis?
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– Nursing diagnosis is the problem statement consisting of the diagnostic label plus etiology
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Types of Nursing Diagnoses
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– Actual Diagnosis – Risk Diagnosis – Health Promotion Diagnosis – Wellness Diagnosis
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Actual Diagnosis
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– Problem presents at the time of the assessment – Presence of associated signs and symptoms
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Risk Diagnosis
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– Problem does not exist – Presence of risk factors
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If a client is vulnerable to developing a health problem, which is most appropriate? A. A wellness nursing diagnosis B. A health promotion diagnosis C. A risk nursing diagnosis D. An actual nursing diagnosis
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C. A risk nursing diagnosis
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Health Promotion Diagnosis
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Preparedness to implement behaviors to improve their health condition Example: Readiness for enhanced Nutrition
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Wellness Diagnosis
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– Describes human responses to levels of wellness in an individual, family, or community – Seeking information & education ** Example: Readiness for Enhanced Family Coping
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Components of a nursing diagnosis
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– Problem statement (Diagnostic label) – Etiology (related factors and risk factors) – Defining Characteristics PED
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Problem statement (diagnostic label)
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– Describes the client’s health problem or response – Qualifiers (deficient, impaired, decreased, ineffective, etc.) added to give additional meaning
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Etiology (related factors and risk factors)
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Identifies one or more probable causes of the health problem
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Defining characteristics
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– Cluster of signs and symptoms indicate the presence of a particular diagnostic label (actual diagnoses) – Actual nursing diagnoses: client’s have signs and symptoms – * For risk diagnoses: no subjective or objective data
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There are always these 3 components of a nursing diagnosis unless what?
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3 pieces unless its risk for then its only problem statement and etiology!
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Ex. Activity Intolerance
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Problem – Activity Intolerance: Insufficient physiological energy to endure or complete required or desired daily activities Etiology/cause (R/T) – Bed rest or immobility – Generalized weakness – Imbalance between oxygen supply & demand – Sedentary lifestyle – THINK NURSING, NOT MEDICAL DIAGNOSIS Defining Characeristics (AEB) – Verbal report of fatigue & weakness – Abnormal heart rate or blood pressure in response to activity – Electrocardiographic changes reflecting arrhythmias or ischemia – Exertional discomfort or dyspnea
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Two types of diagnoses
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1. Medical 2. Nursing
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Medical Diagnosis
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– Made by a physician, NP, or PA (not nurse) – Refers to a disease process – Remains the same for as long as the disease process is present
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Nursing Diagnosis
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– A statement of nursing judgment based on education, experience, expertise and licensed to treat – Describes human response, a client’s physical, sociocultural, psychological, and spiritual responses to an illness or a health problem – Changes when client’s responses change
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ex.
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Activity intolerance related to (R/T) sedentary lifestyle as manifested by (as evidenced by) patient states “I feel tired and weak.”
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Writing Nursing Diagnoses Basic Two-Part Statements
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– Problem (P) – Etiology (E) Ex. Constipation (problem) related to (R/T) prolonged laxative use (etiology) – Risk Diagnoses (D) Client vulnerable to develop health problem Client does not have signs/symptoms! Ex. Risk for injury: Falls R/T leg weakness
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Writing Nursing Diagnoses: Three-Part Statements
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Problem (P) Etiology (E) Signs and symptoms (S) Defining characteristics
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Ex. of 3 part statement
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Example- Situational Low Self-Esteem (problem) R/T feelings of rejection by husband (etiology) as manifested by (AMB) hypersensitivity to criticism; states “I don’t know if I can manage by myself” and rejects positive feedback (signs & symptoms/ defining characteristics)
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Variations of Basic Formats
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– Unknown etiology – Complex factors – Possible – Secondary – Add a “second part
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Unknown etiology **
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defining characteristics are present but nurse does not know cause or contributing factors
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Complex Factors *
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too many etiologic factors or too complex to state in a brief phrase
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Possible
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when the nurse believes more data is needed about the client’s problem or etiology
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Secondary
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: more descriptive; divide etiology into 2 parts; part following secondary often patho/disease/medical diagnosis (Risk for impaired skin integrity R/T decreased peripheral circulation secondary to DM)
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Add a “second part”
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make more precise; Impaired skin integrity (left lateral ankle) R/T decreased peripheral circulation
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Risk for ineffective airway clearance because accumulation of secretion in lungs
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(not related to pneumonia because has to be nursing diagnosis not medical)…….. **** pneumonia
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Avoid Errors in Diagnostic Reasoning
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– Verify – Build a good knowledge base and acquire clinical experience – Have a working knowledge of what is normal – Consult resources: nursing diagnosis handbook & Lippincott Manual – Base diagnoses on patterns, not isolated incidents – Improve critical-thinking skills
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Planning: What is the Goal?
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– Begins with first client contact
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What is planning considered?
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– Ongoing: individualization of initial plan – Continues until nurse-client relationship ends (discharge): what are needs after discharge? –>home care – Multidisciplinary
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The Planning Process
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Consists of following activities: – Setting priorities – Establishing client goals/desired outcomes ** – Selecting nursing interventions – Writing individualized nursing interventions on care plans
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Setting Priorities
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Establishing a preferential sequence for addressing nursing diagnoses and interventions – High priority – Medium priority – Low priority
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High priority
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life-threatening
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Medium priority
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health-threatening
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Low priority
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developmental needs
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When setting priorities, consider..
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– Client’s health values and beliefs – Client’s priorities – Resources available to the nurse and client – Urgency of the health problem Medical treatment plan
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Goals/Desired Outcomes
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– Desired outcomes: specific, observable criteria used to evaluate whether the goals have been met – THE CLIENT WILL…
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SMART Goal
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Specific Measureable Attainable Relevant Time-Bound
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Specific goal
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Who, what, when, where, why, how
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Measureable goal
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How will you know when you’re done
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Attainable goal
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Is it realistic?
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Relevant goal
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How does this fit into the patient’s life now
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Time-Bound goal
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What’s your deadline (need this on goals so know when to start evaluating otherwise never ending)
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Purpose of Desired Goals/ Outcomes
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– Provide direction for planning interventions – Serve as criteria for evaluating progress – Enable the client and the nurse to determine when the problem has been resolved – Help motivate the client and nurse by providing a sense of achievement
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Ask the following questions…
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– What is the client’s problem? – What is the opposite, healthy response? – Constipation – bowel movement, anxiety- less anxious – How will the client look or behave if the healthy response is achieved? (What will I be able to see, hear, measure, palpate, smell or otherwise observe with senses) – What must the client do and how well must the client do it?
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Components of Goal/Desired Outcome Statements
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– Subject – Verb – Condition – Criterion
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Subject
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the client or attribute of client
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Verb
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Kozier page 225- directly observable behavior (ie- apply, describe, state, drink, turn, etc.)
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Condition
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or modifier: explain what, where, when or how
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Criterion
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of desired performance: time or speed, accuracy, distance, & quality
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Length of goals/desired outcomes
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– Can be short-term ( i.e.- by end of shift, by end of week) – Long-term (i.e.- within 2 months, 6 months, etc.)
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Fluid volume deficit The client will drink 100ml of water per hour while awake
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(specific: client, verb is drink, where and why)
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Nursing Interventions and Activities
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– Actions nurse performs to achieve goals – Actually doing something!! – Focus on eliminating or reducing etiology of nursing diagnosis – Treat signs and symptoms and defining characteristics – Interventions for risk nursing diagnoses should focus on reducing the client’s risk factors
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Types of Nursing Interventions
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– Collaborative Interventions – Independent Interventions – Dependent interventions
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Collaborative interventions
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– Actions nurse carries out in collaboration with other health team members – Reflect overlapping responsibilities of health care team
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Independent interventions
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Those activities nurses are licensed to initiate (i.e., physical care, ongoing assessment)
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Dependent interventions
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Activities carried out under physician’s orders or supervision, or according to specified routines
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Criteria for Choosing Appropriate Interventions
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– Safe and appropriate for the client’s age, health, and condition – Achievable with the resources available – Congruent with the client’s values, beliefs, and culture – Congruent with other therapies – Based on nursing knowledge and experience or knowledge from relevant sciences – Within established standards of care
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Writing Individualized Nursing Interventions
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The nurse will… – Verb Action verb starts the interventions and must be precise (i.e.- teach, explain, measure, apply, etc.) – Conditions – Modifiers – Time element When, how long or how often the nursing action is to occur
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Rationale & Resource For the purpose of formulating nursing interventions as a student, please include the:
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– Rationale- the why (bold print) – Resource- where did you get the intervention?
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Relationship of Nursing Interventions to Problem Status
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– Observations – Prevention interventions – treatments – Health promotion interventions
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Observations
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(i.e..- record hourly I & O)
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Prevention interventions
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(i.e..- turn q 2 hours)
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Treatments
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teaching, referrals, physical care
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Health promotion interventions
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when no health problems or when wellness diagnosis used (i.e..- discuss importance of daily exercise)
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Can the intervention be delegated?
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– At times, if appropriate (within scope of practice/abilities and right circumstances) – RN responsible for seeing that delegated tasks are done properly – RN still needs to analyze data, plan care and evaluate outcomes
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Implementing
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– Based on first three phases (assessing- diagnosing-planning) – Provides the basis for the nursing actions performed during the implementing step – Provides actual nursing activities and client responses are examined during evaluating phase
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To implement care successfully, nurses need:
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– Cognitive skills – Interpersonal skills – Technical skills
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Cognitive Skills (Intellectual)
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– Problem solving – Decision making – Critical thinking – Creativity
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Interpersonal Skills
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– Verbal and nonverbal – Effectiveness depends largely with ability to communicate – Therapeutic communication – Necessary for caring, comforting, advocating, referring, counseling, and supporting – Include conveying knowledge, attitudes, feelings, interest – Appreciation of the client’s cultural values and lifestyle
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Technical Skills
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– Purposeful “hands-on” skills – Often called tasks, procedures, or psychomotor skills – Psychomotor refers to physical actions that are controlled by the mind, not reflexes – Require knowledge and frequently manual dexterity
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Five Activities of the Implementing Phase
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1. Reassessing 2. Determining 3. Implementing 4. Supervising 5. Documenting
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Reassessing
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the client: Is the intervention still needed? What is the priority?
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Determining
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the nurse’s need for assistance (safety & does the nurse have the skills)
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Implementing nursing interventions
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use of EBP, knowledge of contraindications, adapt to client preferences, safe care, provide teaching/support/comfort, be holistic, respect privacy/dignity, encourage active participation)
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Supervising
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Supervising delegated care
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Documenting nursing activities:
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record interventions & client responses
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Evaluate: To Judge or Appraise
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– Planned, ongoing, purposeful activity – Determine client’s progress – Effectiveness of care plan Continuous
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What do nurses demonstrates in evaluation?
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responsibility and accountability for their actions
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Relationship of Evaluating to Other Nursing Process Phases
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Depends on the effectiveness of steps that precede: – Assessment data must be accurate and complete – Desired outcome/goal must be stated concretely to be useful for evaluating – Plan must be put into action (implement) to evaluate
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Components of the Evaluation Process
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– Comparing the data with outcomes Goal met, client to… Goal partially met, client only able to… Goal not met, client not able to… (need to modify care plan) – Relating nursing activities to outcomes- Does a new outcome need to be established? – Drawing conclusions about problem status If goals partially or not met: care plan may need to be revised or care plan does not need to be revised but client needs more time – Continuing, modifying, or terminating the nursing care plan
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The primary purpose of the evaluating phase is to determine whether: A. Nursing activities were carried out B. Nursing activities were effective C.Desired outcomes/goals have been met D. Client’s condition has changed
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C.Desired outcomes/goals have been met
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Continuing, Modifying or Terminating the Care Plan
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Critique each phase of the nursing process – Assessing – Diagnosing – Planning – Implementing
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Assessing evaluation
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Incomplete or inaccurate databases influence all subsequent steps
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Diagnosing evaluation
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– Incomplete-new diagnosis statements needed – Complete-analyze whether nursing diagnosis relevant
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Planning evaluation
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– Inaccurate-goals/outcomes need revision – Accurate-goals/outcomes realistic and obtainable – Have priorities changed and client still agrees with priorities? – Write goals & outcomes for any new nursing diagnosis – Do interventions relate to the goal? Were the best interventions selected?
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Implementing evaluation
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– Were interventions clear, reasonable and carried out? – After modifications, begin nursing process again
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Quality Assurance
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– Ongoing, systematic process – Evaluate and promote excellence provision of health care – May evaluate the level of care provided – May be evaluation of performance of one nurse or an agency or country
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Evaluation of 3 components for quality assurance
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1. Structure-focuses on setting 2. Process-focuses on care given 3. Outcomes-focuses on demonstrable changes in client’s health status as a result of nursing care
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Quality Improvement
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Joint Commission Mission “To continuously improve the safety and quality of care provided to the public the provision of health care accreditation and related services that support performance improvement in health care organizations.”
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What is Quality Improvement also known as?
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– Continuous quality improvement (CQI) – Total quality management (TQM) – Performance improvement (PI) – Persistent quality improvement (PQI)
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Documenting: Maintaining Confidentiality of Records
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– For purposes of education and research, most agencies allow students and graduates access to client records – Bound by strict ethical codes and legal responsibility
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How do you protect client’s privacy?
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Protect client’s privacy by not using name or any statements to identify client
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Security for Computerized Records
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– Passwords required and should not be shared – Never leave the computer terminal unattended after logging on – Do not leave client information displayed – Shred all unneeded computer-generated worksheets – Know the facility’s policy and procedure for correcting an entry error – Follow agency procedures for documenting sensitive material Installed firewalls
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Purposes of Client Records
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– Communication – Planning client care – Auditing health agencies – Research – Education – Reimbursement – Legal documentation – Health care analysis
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Source-Oriented Records
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– Traditional client record – Each discipline makes notations in a separate section – Information about a particular problem distributed throughout the record – Narrative charting used
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Problem-Oriented Medical Records (POMR)
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– Data arranged according to client problem – Health team contributes to the problem list, plan of care, and progress notes – Encourages collaboration – Easier to track status of problems – Vigilance required to maintain problem list
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Problem-Oriented Medical Records (POMR) 4 basic components
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1. Database 2. Problem list 3. Plan of care 4. Progress Notes
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1. database
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nursing assessment, PCP history, social & family data, Physical Exam, diagnostic tests
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2. Problem list
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All caregivers contribute
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3. Plan of care
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Primary Care Provider writes physician orders; nurses write nursing orders
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4. Progress notes
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Uses SOAP, SOAPIE, SOAPIER documentation
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PIE Documentation
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– Groups information into three categories: Problem, Interventions, Evaluation – Consists of a client assessment flow sheet and progress notes
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Focus Charting (not on test)
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– Focus on client concerns and strengths – Progress notes organized into – DAR format – Data-assessment phase – Action-planning and implementing phase – Response-evaluation phase – Holistic perspective of client and client’s needs – Nursing process framework for the progress notes
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Charting by Exception (CBE)
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– Incorporates flow sheets, standards of nursing care, bedside chart forms – Agencies develop standards of nursing practice – Documentation according to standards involves a check mark – Exceptions to standards described in narrative form on nurses’ notes
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Documenting Nursing Activities
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– Kardex – Flow Sheets
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Kardex
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May include name, room, age, admit date, diagnosis, provider Allergies Medications, IV fluids Daily treatments Diagnostic procedures ordered Diet Problem list, goals
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Flow sheets
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– Graphic record: vitals, weight – Intake & output record: all routes of intake &output – Medication administration record: order, expiration date, dose, frequency, route – Skin assessment record
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Nursing discharge/ referral summary
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– Description of client’s physical, mental, emotional state – Resolved health problems – Unresolved health problems – Treatments – Current medications – Restrictions: activity, diet, bathing – Functional/self-care abilities – Comfort level – Support networks: family, significant others, home care, etc. – Client education – Discharge destination – Referral services
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Long-Term Care Documentation
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– Based on Health Care Financing Administration & Omnibus Budget Reconciliation Act – Accuracy for Medicare/Medicaid reimbursement
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Home Care Documenting
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– Complete a comprehensive nursing assessment and plan of care – Write a progress note at each visit – Provide a monthly progress nursing summary – Keep a copy of the care plan in the client’s home
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Factors to consider when documenting: Keep to the facts!
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– Date and time – Timing – Legibility – Permanence – Accepted terminology – Correct spelling – Signature – Accuracy *when recording a mistake, draw a single line through it with your initials or name – Sequence – Appropriateness – Completeness – Conciseness – Legal prudence
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Guidelines for Reporting Client Data
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Should be concise, including pertinent information but no extraneous detail
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Types of reporting
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– Change-of-shift report – Telephone reports – Care plan conference – Nursing rounds
question

Guidelines for Change-of-Shift Report
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– Follow a particular order – Provide basic identifying information – For new clients provide the reason for admission or medical diagnosis/ surgery, diagnostic tests and therapies in the past 24 hours – Significant changes in client’s condition – Provide exact information – Report client’s need for emotional support – Include current nurse-prescribed and primary care provider-prescribed orders – Clearly state priorities of care and care due after the shift begins – SBAR format (Situation, – Background, Assessment, Recommendation) – Verification process?
question

Telephone Report: Giving
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– Concise and accurate – SBAR – State the client’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant laboratory data, related nursing interventions – Document the date, time, and content of the call
question

Telephone Report: Getting
answer

– Document date and time – Record the name of person giving the information – Record the subject of the information received – Sign the notation – Repeat information to ensure accuracy
question

Nursing Rounds
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– Two or more nurses visit selected clients at bedside – Nurses obtain information that will help plan nursing care – Provides clients opportunity to discuss their care
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What do you do during nursing rounds?
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– Evaluate the nursing care the client has received
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What measures can the nurse take to maintain confidentiality of the client record (select all that apply)? A. Do not leave paperwork in an unsecured location B. Discard all unneeded paper in the trashcan C. Never leave the computer unattended after logging in D. Do not share personal passwords
answer

A. Do not leave paperwork in an unsecured location C. Never leave the computer unattended after logging in D. Do not share personal passwords
question

When considering the nursing process, the word “identify” is to “recognize” as the word “do” is to: A. Plan B. Analyze C. Evaluate D. Implement
answer

D. Implement
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Which of the following best describes the nursing process? A. It is a solution to all patient problems B. It is only useful in the acute care (hospital) setting C. It is linear, progressing in separate and unrelated steps D. Is a systematic, problem-solving approach to patient care
answer

D. Is a systematic, problem-solving approach to patient care
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Discharge planning should begin: A. Upon first contact with the patient B. The day before discharge C. 24 hours after admission D. When the patient is beginning to recover
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A. Upon first contact with the patient
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Client will ambulate 100 feet without assistance by tomorrow is an example of: A. Short term goal B. Long term goal C. Nursing intervention D. Rationale
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A. Short term goal
question

The nurse has formulated the following diagnosis: Activity intolerance, related to weakness and debilitation, as manifested by reports of fatigue. What is the defining characteristic (signs/symptoms) of this statement? ***** A. Weakness and debilitation B. Activity intolerance C. Physical activity D. Reports of fatigue
answer

D. Reports of fatigue Signs and symptoms PES Problem – physical intolerance Etiology – weakness and debilitation Signs/symptoms – reports of fatigue

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