Principles Final Exam Chap 16-20

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Nursing process:

A professional nurse employs critical thinking to identify, diagnose, and treat human responses to health and illness.

2 steps of Assessment:

1. Collection and verification of data
2. Analysis of all data for developing nursing diagnoses, identifying collaborative problems and developing plan of care.

Purpose of assessment:

To establish a database about the patient's perceived needs, health problems and responses to these problems.

Medical diagnosis:

Identification of a disease condition based on specific evalution of physical signs, symptoms, client's medical history, results of tests and proceedures.

Nursing diagnosis:

Clinical judgement about an individual responses to actual and potential health problems or life processes.

4 types of nursing diagnoses:

Actual, risk, wellness and health promotion.

Actual Nursing diagnosis:

Human responses to health conditions or life porcesses that exist in and individual (family or community); the selection of an actual diagnosis indiciates sufficient data to establish the nursing dignosis.

Risk Nursing diagnosis:

Describes human responses to health conditions/life processes that will possibly develop; the presence of data revealing risk factors is present.

Health Promotion diagnosis:

Personal judgement of individuals motivation/desire to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors.

Wellness diagnosis:

Human response to levels of wellness, where an individual is ready to transition to a higher level of wellness.

ND-two part format:

Nursing diagnosis two part statement for RISK
Part 1: diagnostic label
Part 2: statement of related factors

Diagnostic Label:

The name of the nursing diagnosis as approved by NANDA; label also includes dscriptors used to give additional meaning to diagnosis.

Related factor:

A condition or etiology identified from the patients assessment data, associated w/ patient's actual or potential response to the health problems and can change by nursing interventions.

4 types of related factors:

Pathophysiological, treatment related, situational (environmental or personal) and maturational.

ND-three part statement:

Nursing diagnosis 3 part statement - ACTUAL
Problem-diagnostic label
Etioloty-related to factor (whats contributing to ND)
Symptoms-signs/symptoms-aka-defining characteristics

Sources of Error in ND:

Missing data, lack of knowledge or skill, incorrect interperetation of data-why I do what I do, personal rather than client centered interpretation, Wrong diagnostic label, more than ONE problem per statement.

Planning:

The third step of the nursing process where nurse sets client-centered goals and expected outcomes and plans nursing interventions.

Plan of care:

A ____ __ ____ is dynamic and will change as you meet the patient's needs or identify new needs.

Priority setting:

Ordering of nursing diagnoses/patient problems using notions of ugency/importance to establish a preferential order for nursing actions.

Scales of importance:

High, intermediate and low; can be both physiological and psychological.

High priorities:

Nursing diagnoses that, if untreated, result in harm to the patient.

Intermediate priorities:

Nonemergent, non-life threatening needs of patient.

Low-priorities:

Not always related to specific illness or prognosis, but affect patients future well-being; many focus on patient's long term health care needs.

Goal:

An aim, intent or end; a broad statement that describes the desired change in a client's condition or behavior.

Expected outcomes:

measurable criteria to evaluate goal achievement

Goals/ expected outcomes:

The purpose of ____ and ____ _____ serve two purposes; to provide clear direction for the selection and use of nursing interventions and to provide focus for evaluating the effectiveness of interventions.

Client-centered goal:

Specific and measurable behaviros or responses that reflect a patient's highest possilbe level of wellness and independence in funtion.

Time-limited:

Goals are ___ ____; they are either short term (usually less than a week) or long term (over several days, wks or months).

Expected Outcomes:

____ _____ are specific measurable changes in a patient's status that you expect to occur in response to nursing care.

Several expected outcomes:

Each nursing diagnosis usually has ____ ____ _____.

Sequentially/ move a client toward:

Always write expected outcome _____, with time frames. This give you progressive steps in which to ____ ___ ____ ____recovery and offer an order for nursing interventions.

Measurable terms:

Always write expected outcome statements in ____ _____, allowing you to note specific behaviors or physiological responses expected.

Nursing outcomes classification:

Individual state, behavior or perception that is measurable along a continuum in response to a nursing intervention.

Realistic:

The 7 guidlines for writing goals and expected outcomes are: Client centered, Signal goal/outcome, observable, measurable, time-limited, mutual factors and ____.

Behavior/response:

Each goal and outcome addresses only ONE ____ or ____>

Observe:

You need to be able to _____ if change takes place in a patient's status.

Set standards:

Goals and expected outcomes ___ _____ against which to measure a patient's response to nursing care.

Time frame:

The ___ ____ for each goal and expected outcome indicates when you expect the response to occur.

Mutually:

_____ set goals and expected outcomes ensure that the client and nurse agree on the direction and time limits of care.

Able to reach:

Set goals and expected outcomes that a patient is ____ ___ _____.

Nursing interventions:

Treatments or actions, based upon clinical judgments and knowledge, that nurses perform to meet patient outcomes.

3 Categories of NI:

nurse-initiated, physician-initiated and collaborative interventions.

Nurse-initiated interventions:

The independent nursing actions that a nurse initiates, which do not require direction/orders from another HC professional; autonomous actions based on scientific rationale.

Physician-initiated interventions:

Dependent nursing intervention that require an order from a physician or another HC professional; each requires specific responsibility and technical nursing knowledge.

Collaborative interventions:

Therapies that require the combined knowledge, skill and expertise of multiple HC professionals.

Nursing care plans:

Include nursing diagnoses, goals/expected outcomes and specific nursing interventions so any nurse is able to quickly identify a patient's need and situation.

Continuity:

The nursing care plan enhances the _____ of nursing care by listing specific nursing interventions needed to achieve the goals of care.

Critical pathways:

Are multidisciplinary treatment plans that outline the treatments or interventions dlients need to have while they are in a health care setting for a specific disease or conditon.

Nursing intervention:

Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enchanc client outcomes.

Direct Care Interventions:

Are treatments performed through interactions with patient's.

Indirect care interventions:

Treatments performed away from the client but on behalf of the client. Ex: safety, infection control, documentation.

Standing Order:

a preprinted document containing orders for the conduct of routine therapies, monitoring guidlines, and/or diagnositic procedures for specific clients w/identified clinical problems.

Adverse reaction:

A harmful or unintended effect of a medication, diagnostic test or therapeutic intervention.

Evaluation:

Determining whether after application of the nursing process, the patient's condition or well-being improved.

Evaluative measures/nursing:

You conduct ____ ____ to determine if you met expected outcomes, not if ____ interventsion were complete.

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