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55 terms

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.