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44 terms

N190 test 1 nursing process

STUDY
PLAY
what is a nurse??
problem solving; we use the nursing process to determine problem and need identification; requires critical thinking/clinical judgement
different kinds of knowledge
theoretical knowledge; practical knowledge; ethical knowledge; self knowledge
theoretical knowledge
info, facts, principles, evidence based theories and research
practical knowledge
knowing what to do and how to do it
ethical knowledge
knowledge of your obligations and knowledge or right and wrong; ability to use moral principles to make decisions
self knowledge
self understanding awareness of your beliefs values culture and religious biases
Virginia Henderson quote
Nursing includes the head (intellect) the hands (skills) and the heart (caring)
ADPIE
Assessment Diagnosis Planning/Outcomes Implementation Evaluation
nursing process
a systemic problem solving process that guides all nursing actions; involves both thinking and doing; you can apply the process to sick and well pts; this process assists the nurse in providing goal directed, pt centered care
subjective data
a process of systemically collecting, organizing, validating and documenting data about pt's health status; interview/health assessment; what the pt reports
objective data
physical examination; records review; labs; diagnostics vital signs; if a significant other reports something it should be validated or verified
Nursing process diagnosis
not a medical diagnosis(a medical diagnosis is an identification of a disease based on scientific evaluation of S/S); nursing diagnosis classifies health problems that are within our (nursing's domain); a clinical judgement about a pt, family or community; describes actual or potential response to a health problem; a potential problem is a "risk for" problem
a nursing process as a two part statement
1. the NANDA label; 2.the factors causing or contributing to the problem
Label
the name of the nursing diagnosis as approved by NANDA international
NANDA label
identifies the pt's problem; indicated by assessment data and the factors causing or contributing to the pts risk for vulnerability to a problem; uses few words as possible
nursing process diagnosis cont.....
uses descriptors; compromised, decreased, deficient, delayed, effective, imbalanced, impaired, increased....DO NOT use as a medical diagnosis
PES
P=problem; (NANDA) ex; impaired physical mobility E= etiology; related factor; S= symptoms; ex evidenced by restricted turning
First label
once you identify a nursing diagnosis...ask yourself what is the best way to resolve this problem
related to statement for nursing process diagnosis
what the problem is related to should be the etiology of the problem...this is NOT a medical diagnosis
condition or etiology
identified from the pt assessment data; this can be the pt's actual or potential response to a health problem can be changed by using nursing interventions
nursing process diagnosis as evidenced by...
list subjective data first then list objective data; a correct written nursing diagnosis is written in correct NANDA format; don't ever use the word understand it is not observable or measurable ex: airway clearance r/t reluctance to cough due to incisional pain
Planning/outcomes
must be specifically stated and measurable; prioritize outcomes; set goals; interventions; document; individualized and specific to pts-this is the action plan; goals and outcomes provide you focus for what interventions are needed; specifically stated and measurable-outcomes must be measurable, specific, descriptive and observable; must be realistic and achievable, should indicate a time frame for achievement; should take into consideration the pt's desires and resources
Implementation of Interventions
- Nursing Intervention Classfication (NIC)
- A nursing intervention is a treatment or action based on clinical judgement & knowledge that we perform to meet pt outcomes
- Interventions must be measurable ex. how frequently, or how far. . .
- To choose nursing interventions, you must know;
1. the scientific rationale for the intervention
2. possesses the necessary skills (motor & interpersonal)
3. be able to function within a particular setting to use the resources effectively
*Interventions are designed to prevent, reduce, or eliminate patients health problem
Implementation of Interventions
- Make sure when writing interventions that you include how frequently & how far
- To be an effectively written nursing intervention it must include those elements.
*Interventions must have rationale - change position - give hot/cold compressions, talk with patient interventions consist of caring out interventions (strategies) designed to assist the pt in achieving goals.
Evaluation
- ongoing
- compare current with the expected outcomes identified earlier.
- met, not met, partially met.
- supporting data
- decision - continue? modify? or discontinue?
- modifications
you are measuring the pt's response in nursing interventions evaluations are constant
Success requires Basic Abilities
- Knowledge of science & theory (nursing, medical, psychology, pharmacology)
- Creativity (Jane's story of Alzheimer's patient taking out IV)
- Commitment (to your patients)
- Intelligence
Critical Thinking
- What is it? Critical thinking is a combination of reasoned thinking, openness to alternatives, an ability to reflect, & a desire to seek the truth".
- Why is critical thinking important to nurses?
-Do we just give medications and chart that we did (ex. always check blood glucose before insulin injection)
- Do we just listen to lungs & write that we did (ex. compare to previous charting)
- Nursing is about doing. . .and thinking.
3 Levels of Critical Thinking
Level 1. Basic Critical Thinking - Relies on rules & procedures to perform correctly. Following a procedure step by step. Giving meds on time. Relies on experts to have the right answer to the problem.
Level 2. Complex Critical thinking - analyzes alternatives and considers risks and benefits before making a decision. Examines choices independently. Knowing that alternative solutions do exist (ex. discussing alternative pain management techniques).
Level 3. Commitment - acts out of commitment, assessing many variables & assuring accountability. Anticipates the need to make choices with out assistance from others.
T.H.I.N.K.
T - total recall: remembering essential or needed facts.
H - Habits: behaviors that have been repeated many times & are second nature
I - Inquiry: examine issues going on & questions the situation.
N - New ideas: creativity
K - Know: how you think, recognize logical thinking
Critical Thinking Model - Specific knowledge Base
Basic education. Ability to separate relevant from irrelevant data, & important data from unimportant data
Critical Thinking Model - Experience
Reflection on practice. Evaluate the credibility & usefulness of sources of info. Organize & group the data in meaningful ways. Visualize potential conclusions.
* If you need to seek consultation 1. Direct consult to right professional. 2. Provide consult with relative info. on the problem. 3. Identify the problem
Critical Thinking Model - Competencies.
Problem solving. Applying research and decision making. Make inferences & conclusions. And explore the advantages, disadvantages & possible consequences of each action.
*What's your rationale? Stay with in your scope of practice. Dr orders are not suggestions.
Critical Thinking Model - Attitude.
Confidence, think, independently, fairness, responsibility, risk taking, discipline, perserverance, creativity, integrity, humility.
- Don't believe everything you are told. "What is your rationale?"
- Objectively gather and recognize the need for more information. Listen carefully. Read thoughtfully. Recognize the gaps in one's own knowledge.
Critical Thinking Model - Standards.
Intellectual standards & professional standards.
- Stay within our scope of nursing.
Nursing Process
"A systematic approach for gathering pt data (assessment), critically examining and analyzing the data, identifying the pt's response to a health problem (nursing Dx), determining priorities, est. goals & expected outcome of care (plan), taking appropriate action (implement) and then evaluating whether that action is effective (evaluation). ADPIE
Nursing Process
A - Assessment
D - Dx
P - Plan
I - Implementation
E - Evaluation
Nursing Languages (NANDA, NIC, NOC)
NANDA - Nursing American Nursing Dx
NIC - Nursing Intervention Classification
NOC - Nursing Outcomes Classification
Assessment
History, Function health patterns, physical assessment, report from other health care professionals, & medical record
Critical Thinking Model (Specific Knowledge Base)
- This education & we are laying a foundation for you to build your own practice on.
Nursing Process Plan
What are we going to do about the problem?
- expected outcomes
- Nursing interventions
Individualize & prioritize the patient
Make specific & measurable
Nursing Process - Implement
- Perform previously identified nursing interventions.
- Document interventions & ongoing assessment of patient response
Nursing Process - Evaluation
- Ongoing
- Review previous "expected outcome"
- met
- not met
- supporting data
- decision
- modifications
Putting it all together
Use both the Nursing Process & Critical Thinking to develop a nursing care plan for your pt.
- Why a care plan?
From Care Plans to Concept Maps
What is a concept map?
- A visual representation of pt problems & interventions that show their relationship to one another.
- Why use a concept map?
A significant advantage of concept map over a linear care plan is that it shows interconnection in the delivery of care (lab tests, meds, Dx are not linked on the care plan).