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.
Identification of a disease condition based on specific evalution of physical signs, symptoms, client's medical history, results of tests and proceedures.
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.
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
The name of the nursing diagnosis as approved by NANDA; label also includes dscriptors used to give additional meaning to diagnosis.
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.
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.
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.
Nursing diagnoses that, if untreated, result in harm to the patient.
Nonemergent, non-life threatening needs of patient.
Not always related to specific illness or prognosis, but affect patients future well-being; many focus on patient's long term health care needs.
An aim, intent or end; a broad statement that describes the desired change in a client's condition or behavior.
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.
Specific and measurable behaviros or responses that reflect a patient's highest possilbe level of wellness and independence in funtion.
Goals are ___ ____; they are either short term (usually less than a week) or long term (over several days, wks or months).
____ _____ 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.
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.
The 7 guidlines for writing goals and expected outcomes are: Client centered, Signal goal/outcome, observable, measurable, time-limited, mutual factors and ____.
Each goal and outcome addresses only ONE ____ or ____>
You need to be able to _____ if change takes place in a patient's status.
Goals and expected outcomes ___ _____ against which to measure a patient's response to nursing care.
The ___ ____ for each goal and expected outcome indicates when you expect the response to occur.
_____ 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 ____ ___ _____.
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.
The independent nursing actions that a nurse initiates, which do not require direction/orders from another HC professional; autonomous actions based on scientific rationale.
Dependent nursing intervention that require an order from a physician or another HC professional; each requires specific responsibility and technical nursing knowledge.
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.
The nursing care plan enhances the _____ of nursing care by listing specific nursing interventions needed to achieve the goals of care.
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.
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.
a preprinted document containing orders for the conduct of routine therapies, monitoring guidlines, and/or diagnositic procedures for specific clients w/identified clinical problems.
A harmful or unintended effect of a medication, diagnostic test or therapeutic intervention.
Determining whether after application of the nursing process, the patient's condition or well-being improved.
You conduct ____ ____ to determine if you met expected outcomes, not if ____ interventsion were complete.