46 terms

Nursing Process and Critical Thinking

Protection, promotion and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of ind, families, communities and populations
nursing process
serves as the organizational framework for the practice of nursing.
nursing process
systematic method by which nurses plan and provide care for patients
Nurse process 6 phases
assessment, diagnosis, outcome identification, planning, implementation and evaluation
the RN collects comprehensive data pertinent to the patient's health or the situation
the RN analyzes the assessment data to determine the diagnoses or issues
outcome identification
the RN identifies expected outcomes for a plan individualized to the patient or situation
the RN develops a plan that prescribes strategies and alternatives to attain expected outcomes
the RN implements the identified plan
the nurse evaluates the patient's progress toward attainment of outcomes
systemic, dynamic process by which the nurse through interaction with the client analyzes data about the client
synonym for subjective and objective data
subjective data
verbal sttements provided by the patient
objective data
observable and measurable signs
biographic data
provide info about the facts or events in a person's life
a large store or bank of info from which nursing diagnoses can be identified.
data clustering
occurs when related cues are grouped together, also assists in identification of nursing diagnosis
identify the type and cause of a health condition; clinical judgment 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
any health care condition that requires diagnostic, therapeutic or education action
guidelines to help nurse identify the cues
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
North American Nursing Diagnosis Association
Four Components of Nursing Diagnosis
1. nursing diagnosis title/label. 2. definition of the title/label. 3. contributing/etiologic/related factors and 4. defining characteristics
defining characteristics
clincal cues, signs and symptoms that furnish evidence that the problem exists
actual nursing diagnosis
human responses to health condition/life processes that exist in an ind, family, or community; three part statement, words "related to" links the first and second parts of the statement. "manifested by" joins the second and third parts of the diagnostic statement ex. constipation related to insuff fluid intake manifested by abdominal distention, no bowel movement for 5 days and straining at stool
risk nursing diagnosis
human responses to health conditions/life processes that may develop in a vulnerable ind, family or community; two part statement connected by words "related to" ex. risk for impaired skin integrity related to mechanical forces
syndrome nursing diagnosis
used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances; one part statement ex. rape-trauma syndrome has the etiology provided in the label itself
wellness nursing diagnosis
juman responses to levels of wellness in an ind, family or community that have a readiness for enhancement; written as a one part statement. Words "readiness for enhanced" are used ex. readiness for enhanced nutrition
collaborative problems
certain physiologic complications that nurses monitor to detect onset or changes in status. ex. potential complication: hypoglycemia
medical diagnosis
identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test and procedures; physicians make these diagnoses. ex. congestive heart failure
statement about the purpose to which an effort is directed. Exm. the nurse might want to prevent constipation or promote activity
states the behaviors that the patient will be able to perform rather than what the nurse will do.
measurable verbs
ex. describe, list, walk, demonstrate and verbalize
nursing establishes priorities of care, selects and converts nursing interventions into nursing orders and communicates the plan of care using standardized languages or recognized terminology to document the plan
nursing interventions
those activities that should promote the achievement of the desired patient outcome
physician-prescribed interventions
those actions ordered by a physician for a nurse or other health care professional to perform
nurse-prescribed interventions
any actions that a nurse can legally order or begin independently
nursing orders should include:
date, signature of nurse responsible for the care plan; subject action verb; qualifying details
established plan is put into action to promote outcome achievement includes ongoing activities of data collection, prioritization, performance of nursing interventions and documentation
determination made about the extent to which the established outcomes have been achieved
standardized language
structured vocabulary that provides nurses with a common means of communication
nursing-sensitivities outcomes
the results of outcomes of nursing interventions. These outcomes or indicators are influenced by nursing and can be used to judge effectiveness of care and determine best practices
managed care
a health care system that involves adminstrative control over primary health care services in a medical group practice. Redundant facilities and services are eliminated and costs are reduced. Health education and preventive medicine are emphasized
case management
the assignment of a health care provider to oversee the case of an ind patient
clinical pathways
multidisciplinary plan that schedules clinical interventions over an anticipated time frame for high risk, high volume, high cost types of cases
the unexpected event that occurs during the use of a clinical pathway; can be positive or negative