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58 Cards in this Set

  • Front
  • Back
a systematic, dynamic process by which the nurse, thru interaction w/the pt., significant other, and health care providers, collects info and analyzes data about pt.
Components of Assessments
Cognitive, psychosocial, emotional, cultural, and spiritual
Focused assessment is advised when...
pt. is critically ill, disoriented, or unable to respond
Subjective Assessment
Verbal statements provided by the pt. Example: the pt. states they are having trouble breathing
Objective Assessment
Observable and measurable signs, can be recorded, example: pt. breath sounds are diminished bilaterally thru the bases
Primary & most accurate source of data
the patient
Secondary source of data
family members, significant other, medical records, diagnostic procedures, and nursing literature; when pt. is unable to supply info, these sources are used
2 methods of data collection
1. interview
2. physical exam
Data collected during interview:
1. biographical data
2. reason pt. is seeking health care
3. history of present illness
4. past health history
5. environmental history
6. psychosocial history
2 types of physical exams
1. head-to-toe format
2. focused assessment
Data clustering
related cues grouped together, attention is focused on health concerns that need support and assistance, this assists in the identification of nursing dx
ID the type and cause of a health condition; ANA defines as "A clinical judgement about the patients response to actual or potential health conditions or needs; this provides the basis for determination of a plan of care to achieve expected outcome
Who may observe and collect data?
the LPN or RN may both observe and collect data
Any health care condition that requires diagnostic, therapeutic, or educational actions, deviations from the pop. norms, any chg in the pts. usual health status, any dysfunctional behavior
Nursing Diagnosis
a clinical judgement about an individual, family, or community response to actual or potential health problems or life processes; provides basis for selection of nursing interventions
Nurses can legally...
identify and prescribe the primary interventions to treat or prevent problems that are nursing diagnoses
Components of Nursing Diagnosis
1. Nursing diagnosis title/label
2. Definition
3. Contributing / Etiologic / Related factors and risk factors
4. defining characteristics
Nursing Diagnosis Title/Label
provides a concise name for the identified health problem; adjectives add meaning to the nursing diagnosis - imbalanced, impaired, etc.
Presents clear, precise description of the problem; helps to identify the difference between similar diagnoses
contributing / etiologic / related factors and risk factors
conditions that might be involved in the development of a problem and are found in the nursing diagnosis; may become focus for nursing interventions; written as "related to"
Risk Factors
those that increase the susceptibility of a patient to a problem
Defining characteristics
cues that tell how the diagnosis is manifested; clinical cues, signs, and symptoms that furnish evidence that a problem exists; written as "manifested by".
Risk Nursing Diagnosis
a clinical judgement that an individual, family, or community is more vulnerable to develop the problem than others in the same or similar situation; 2 part statement (label & risk factor)
Possible Nursing Diagnosis
used when a problem is considered feasible; add'l data must be gathered to confirm or rule out the prob; written in 2 part statement (label & cont. etilogic risk factor)
Syndrome Nursing Diagnosis
used when a cluster of actual or risk nursing diagnoses are predicted to be present in certain circumstances ( 1 part statement)
Current syndrome diagnoses:
post-trauma syndrome, rape-trauma syndrome, risk for disuse syndrome, impaired environmental interpretation syndrome, and relocation stress syndrome
Wellness Nursing Diagnosis
a clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness; written in 1 part statement (readiness for enhanced...)
Collaborative Problems
certain physiologic complications that nurses monitor to detect onset or changes in staus; nurses manage problems using md-prescribed and nurse-prescribed interventions to minimize the complications
Medical Diagnosis
the identification of a disease or condition through a scientific evaluation of physical signs, symptoms, history, laboratory tests, and procedures
nurse est. priorities of care, writes desired pt. outcome, selects and converts nursing interventions into nursing orders, & communicates the plan of care
Priority Setting
nursing diagnoses are ranked in order of importance for the pts. life and health; physiologic needs come 1st; actual problems may be ranked before risk problems
Maslow's Hierarchy of Needs
1. physiological needs
2. security and safety
3. love and belonging
4. self-esteem
5. self-actualizaiton
Why include pt. in planning?
validates his/her importance as an individual and motivates him to participate in their health care and adhere to care plan; gives them greater sense of control
Est. desired pt. outcomes
nurse predicts the condition of the pt. following nursing interventions; expressed in a statement that indicates degree of wellness desired, expected, or possible for pt. to achieve
a statement provides a description of the specific, measurable behavior that the pt. will be able to exhibit in a given time frame following the intervention
a statement about the purpose to which an effort is directed
A well-written patient-centered goal / desired outcome statement achieves teh following:
1. uses the word "patient"as the subject of the statement
2. uses a measurable verb
3. is specific for the pt. and the pts. problem
4. is realistic for the pt. and the pts. problem
5. includes a time frame for pt. reevalution
Four elements of Outcome Statement:
1. B (Behavior) desired behavior
2. M (measure) criteria for measuring behavior
3. C (conditions) condition in which behavior shld occur
4. T (time frame) when the behavior shld occur
Physician prescribed interventions
actions ordered by physician for a nurse or other health care provider to perform; meds, wound care, dx tests; nursing judgement still used; assessing, teaching, & validating safety of phys. orders expected of nursing practice
Nurse-prescribed intervention
actions the nurse can legally order or begin independently; providing a back massage, turning pt. q2h, etc.
Nursing orders should include:
1. date
2. signature of the nurse responsible for the plan of care
3. subject (who will carry out order)
4. action verb
5. qualifying details
phase of nursing process in which established plan is put into action to promote achievement of the outcome
A vital component of the implementation phase is...
documentation; if it was not charted, it was not done!
Implementation - expect to perform the following:
routine assessment & monitoring, therapeutic interventions, offering comfort, providing nourishment, helping w/ADL's, supporting resp. & elimination functions, providing skin care, emotional support, pt. teaching & counseling, communication w/other interdisciplinary team members
a determination is made about the extent to which the established outcomes have been achieved
3 judgements of evaluation:
1. The outcome was achieved
2. The outcome was not achieved
3. The outcome was partially achieved
Managed Care
a health care system whose aim is to enhance specific clinical and financial outcomes within a specific time frame
Case Management
a certified nursing specialty; refers to the assignment of a health care provider to a pt. so that the care of that pt. is overseen by one individual; assists the pt. and family to receive required svc's, coordinates these services, and evaluates the adequacy of these svc's.
Clinical Pathways
multidisciplinary plan that schedules clinical intervention over an anticipated time frame for high-risk, high-volume, high-cost types of cases
Role of LPN
provided direct bedside nursing care, closely observe, prioritize, intervene, and evaluate the care provided to and for the pt.
Role of LPN in assessment
observe and report significant cues to the charge nurse or phys.
Role of LPN in diagnosis
assist with the determination of accurate nursing diagnoses; gather data to confirm or eliminate problems
Role of LPN in planning
assist w/ setting priorities, suggest interventions, assist w/ the development of realistic pt-centered desired pt. outcomes
Role of LPN in implementation
assist with the establishment of priorities, carry out phys. and nursing orders, evaluate the effectiveness of nursing activities
Role of LPN in evaluation
assist with reevaluation of the pts. health state after nursing interventions, suggest alternative nursing interventions when necessary