FON Ch. 5
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Created by:
MaryLouiseBrown on September 8, 2009
Subjects:
Nursing Process & Critical Thinking
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54 terms
Terms | Definitions |
|---|---|
 Nursing | Nurisng is the protection, promotion, & optimization of health & abilities, prevention of illness & injury, alleviation of suffering through the diagnosis & treatment of human response, & advocacy in the care of individuals, families, communities, & populations |
| Nursing Process | includes six phases: 1) assessment, 2) diagnosis, 3)outcome 4) identification, 5) planning, 6) implementation, and evaluation |
| (1) Assessment: | The registered nurse collects comprehensive data pertinent to the patient's health or the situation |
| (2) Diagnosis: | The registered nurse analyzes the assessment data to determine the diagnoses or issues |
| (3) Outcome Identification: | The registered nurse identifies expected outcomes for a plan individualized to the patient or situation |
| (4) Planning: | The registered nurse develops a plan that prescribes strategies and alternatives to attain expected outcomes |
| (5) Implementation: | The registered nurse implements the indentified plan |
| (6) Evaluation: | The nurse evaluates the patient's progress toward attainment of outcomes |
| Cue | Synonym for subjective & objective data |
| Subjective Data | information collected form residents, family members, or friends; information may or may not be true but it is what person reported, also called symptoms .ie - "Ms. Jones says her foot is itchy." |
| Objective Data | observable, measurable (see, touch, hear, smell). Objective data that can be recorded. |
| Primary Source | Patient is primary source from which to collect data. Must be alert & oriented. |
| Secondary Source | Include family members, significant others, medical records, diagnostic procedures, & nursing literature when the patient is unable to supply informaton because of deterioration of mental status, age, or seriousness of illness. Other healthteam professsionals also help. |
| Biographic Data | 1st method of data collection. Name, gender, address, date of birth, birthplace, occupation, reason patient is seeking health care, a history of present illness, health history, & family history. |
| Physical Examination | 2nd method of data collection. An assessment of each part of the pt's body to obtain objective data about the pt that assists in determining the pt's state of health. Also guided by subjective data provided by the patient. Statement of pain from patient is followed by examining that part of the body, etc. |
| Database | A large store or bank of information from which nursing diagnoses can be identified. Information also available from physician. |
| Data Clustering | occurs when related cues are grouped together, also assists in identification of nursing diagnosis. |
| Diagnose | To identify the type & cause of a health codition. A clinical judgement about the client's response to actual or potential health conditions or needs. Provides the basis for determination of a plan of care to achieve expected outcomes. LPN & RN may observe & collect data, than analyze data, RN responsible for analyzing & interpreting data to identify health problems. |
| Problem | Any health care condition that requires diagnostic, therapeutic, or educaitonal action. |
| Significant Cues for Nursing Care | (1) Deviations from population norms; (2) Any change in the patient's usual health status; (3) Developmental delays; (4) Dysfunctional behavior; & (5) Changes in usual behavior. |
| Nursing Diagnosis | This is a clinical judgment about individual, family, or community responses to actual or potential health problem/life processes. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. Nurses can legally identify and prescribe the primary interventions to treat or prevent problems that are nursing diagnoses. By definition, if the nurse cannot prescribe the primary treatment, the problem is NOT a nursing diagnosis. |
| Components of a Nursing Diagnosis | Following 4 components are addressed when nursing diagnosis is submitted: (1) nursing diagnosis title/label; (2) Definition of the title/label; (3) Contributing/etiologic/related factors; & (4) Defining characteristics. |
| Nursing Diagnosis Title/:Label | The problem identified after cue clustering & analysis is given a title, or label. Problem frequently is called the nurisng diagnosis. Provides a concise name for the identified health problem. |
| Definition | Definiton presents a clear, precise description of the problem. This description helps identify the difference between similar nursing diagnoses. |
| Contributing/etiolgic/related factors | Conditions that may be involved in the development of a problem & also found in nursing diagnosis handbooks. Become focus of nursing intervention. |
| Defining Characteristics | Clinical cues, signs, & symptoms that furnish evidence that the problem exists. The cues, signs, and symptoms that were identified inthe patient's assessment are written as the "manifested by" in the nursing diagnosis statement |
| Three Parts of Actual Nursing Diagnosis | (1) The nursing diagnosis label from the NANDA list; (2) The contributing/etiologic/related factor; & (3) The specific cues, signs, & symptoms from the patient's assessment. |
| Risk Nursing Diagnosis | Two part statement: (1) The nursing diagnosis label from the NANDA list & (2) the risk factors. Connected with the words "related to". |
| Wellness Nursing Diagnosis | Is written as a one-part statement: The human responses to levels of wellness in an individual, family, or community that have a readiness for enhancement. Contain the words "readines for enhanced". |
| Collaborative Problems | Certain physiologic complications that nurses monitor to detect onset or changes in status. Nurses manage these using physician-prescribed and nursing prescribed interventions to minimize the complications of the events |
| Medical Diagnosis | Identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test, and procedures. Physician makes medical diagnoses. Ex. CHF, pneumonia, diabetes mellitus, & hepatitus B |
| Chart | Health care record: it is a legal record that is used to meet the many demands of the health, accreditation, medical insurance & legal systems |
| Charting, Recording, Documenting | Process of adding written information to the chart |
| Purposes of Patient Records | Written communication, permanent record for accountability, legal record of care, teaching, & research & data collection |
| Diagnosed Related Groups | DRG's: a system that classifies patients by age, diagnosis, and surgical procedure, producing 300 different categories used in predicting the use of hospital resources including the length of stay |
| Legal Document | patients chart or health record is a legal document |
| traditional chart | Divided into specific sections or blocks. |
| Narrative Charting | a descriptive record of client data and nursing interventions, written in sentences and paragraphs |
| Problem Oriented Medical Record | POMR- includes a database, problem list, educational, diagnostic, treatment plan, and progress notes |
| SOAPIER | SUBJECTIVE, objective, assessment or analysis, plan, interventions evaluation , revision |
| SOAPE | Charting format used in POMR. Components include subjective data (S) reported by the patient; objective data (O) acquired by inspection, percussion, auscultation and palpation and by tests, usually measurable findings; assessment (A) of the problem; plan (P) of care; and evaluation (E) of the patient's response to the treatment plan |
| Focus Charting Format | Data, Action, Response/evaluation, Education/patient teaching DARE nurisng diagnosis nursing use this |
| Charting By Exception CBE | the only thing that is documented is abnormal assessment findings and nursing care that deviates from written standards. No normal findings or routine care is charted. |
| Incident Report | a special form that is completed for each accident or unusual occurrence in a long-term care facility; it describes what happened and contains other important info |
| Nursing Care Plan | incorporates nursing diagnosis, critical pathway information, and physician-ordered and nursing-ordered care |
| Twenty Four Hour Patient Care Records | Consolidation of the nursing records into a system that accommodates a 24-hour period. Aids in the elimination of unnecessary record-keeping forms. |
| Acuity Charting Forms | Acuity means how much nursing hours need to go into the patients recovery process. Filled out every shift. What kind of staffing needs are needed for next shift. |
| Clinical Pathways (Critical) | daily flow charts that track the client's clinical symptoms, nursing diagnoses, nursing interventions as well as interventions by members of the multidisciplinary treatment team, and nursing outcomes |
| Record Ownership and access | Original health care record or chart is the property of the institution or physician |
| What does a well-written patient-centered goal/desired patient outcome statement does the following: | 1) Uses the word patient or a part of the patient as the subject of the statement 2) Uses a measurable verb 3) Is specific for the patient and the patient's problem 4) Is realistic for the patient and the patient's problem 5) Includes a time frame for patient reevaluation. Need to use "The patient will" or "The patient's ....will." Measurable verbs indicate the precise behavior that the nurse anticipates hearing or seeing. Define, describe, list, walk, deomonstrate, and verbalize are examples of measurable verbs. Patient outcome statement needs to be realistic to their problem. A time frame is written into the patient outcome to provide a deadline for evaluation of the patient's progress. |
| What is Included in a Nursing Order | Date, Signature of nurse responsible for the care plan, Subject (who will be carrying out the activity), Action Verb, & qualifying details |
| NANDA | North American Nursing Diagnosis Association. Describes five types of nursing diagnoses; Actual, risk, possible, wellness, and syndrome. |
| Role of the LPN in Nursing Process | 1) Assessing: Observe and report significant cues to the nurse in charge or to the physician. 2) Diagnosing: Assist with the determination of accurate nursing diagnoses. Gather further data to confirm or eliminate problems, 3) Expected Outcomes/Planning: Assist with setting priorities. Suggest interventions. Assist with the development of realistic patient-centered goals/desired patient outcomes. 4) Implementing: Assist iwth the establishment of priorities. Carry out physician and nursing orders. Evaluate the effectiveness of nursing activities. 5) Evaluating: Assist with the reevaluation of the patient's health state after nursing interventions. Suggest alternative nuring interventions when necessary. |
| Critical Thinking | thinking that does not blindly accept arguments and conclusions. Rather, it examines assumptions, discerns hidden values, evaluates evidence, and assesses conclusions. |
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