Nurse Process And Critical Thinking

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Nursing process

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A systematic method of which nurses plan and provide care for patients this involves a problem-solving approach that enables a nurse to identify patient problems and potential problems once these problems are identified the nurses able to plan deliver and evaluate Nursing Care in an orderly scientific manner

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Assessment

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A systematic Dynamic process by which registered nurse through interaction with the patient family groups communities population Health Care Providers collect and analyze data assessment may include the following Dimensions physical psychological social cultural spiritual conative functional abilities economic devlopmental and lifestyle

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Subjective data

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Refer to information that is provided by the patient statements about nausea and description of pain fatigue and anxiety or examples of subjective data

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Objective data

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Are observable and measurable signs for example the LVN is able to observe capillary refill measure a patient's blood pressure and observe and measure edema other terms for objective data or signs and objective cues

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Primary source of data

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In most instances the patient is considered to be the most accurate reporter.

A alert and oriented patient is able to provide information about past illnesses and surgeries and present signs symptoms and lifestyle

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Secondary source

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When the patient is unable to supply adequate information because of deterioration of mental status age or seriousness of illness the nurse turns II sources which are the family members significant others medical records diagnostic procedures and previous nursing progress notes

Healthy professionals are also helpful secondary sources Health Care Providers nurses dietitian respiratory and physical therapist and other frequently provided data about the patient

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Biographic data

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Provide information about the facts or events in a person's life additional information collected includes a reason the patient seeking Health Care a history of present illness the health history and family history environmental history

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Database

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A large store or Bank of information analysis of database leads to identification of nursing diagnosis in addition the database makes information available for the health care provider who assists in medical management of the patient and all Healthcare Personnel who are involved in the patient's care

analysis of database leads to identification of nursing diagnosis in addition the database makes information available for the health care provider who assists in medical management of the patient and all Healthcare Personnel who are involved in the patient's care

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Data clustering

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Data clustering is one method of data organization the clustering of related data helps identify patterns that assist with identification of nursing diagnosis some schools of nursing or Healthcare facilities use the term defining characteristics as a synonym for data clustering

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Diagnosis

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Is to identify the type and cause of health conditions that the ANA defines diagnosis "as clinical judgment about the client's response to actual or potential health conditions or needs the diagnosis provides the basis for determination of the plan of care to achieve expected outcomes"

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Nursing diagnosis

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Is the type of health problem that can be identified

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NANDA-I

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To reflect nursing diagnosis terminology that is used across the world

NANDA-I approves the official definition for a nursing diagnosis a nursing diagnosis "is a clinical judgement about actual or potential individual family or Community responses to health problems life processes a nursing diagnosis provides basis for selection of Nursing interventions to achieve outcomes for which the nurse has accountability"

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Defining characteristics

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Arc the clinical cues signs and symptoms that furnish evidence that the problem exists

the cues signs and symptoms that were identified in patients assessment are prefaced with "as evidence by" in the nursing diagnosis statement

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Risk factors

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Are circumstances that increase the susceptibility of the patient to a problem risk factors are written as the "related to" in risk nursing diagnostic statements

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Actual nursing diagnosis

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A clinical judgment about Human Experience responses to health conditions life processes that exist in an individual or family or community

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Risk nursing diagnosis

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a clinical judgment that describes human responses to health conditions life processes that may develop invulnerable individual family community it is supported by risk factors that contribute to increased vulnerability

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Syndrome nursing diagnosis

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A clinical judgment describing a specific cluster of nursing diagnosis that occur together in our best address together and through similar interventions

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Wellness nursing diagnosis

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A clinical judgment about a person's family or communities motivation and desire to increase well-being and actualize human health potential as expressed in Readiness to enhance specific Health behaviors and can be used in any health state

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Medical diagnosis

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The identification of a disease or condition with evaluation of physical signs symptoms patient interview Laboratory test diagnostic procedures review medical records and patient history the health care provider is licensed to make and treat medical diagnosis examples are congestive heart failure and pneumonia diabetes and hepatitis B

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Planning

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Phase of the nursing process priorities of care established in the nursing interventions or chosen to best address the nursing diagnosis the information is typically communicated through the care plans so that all Healthcare Personnel directly involved in the care of the patient can follow the same plan resulting in continually of care

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Nursing interventions

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Are those activities that promote the chief mate of desired patient outcomes

Interventions include activities at the nurse selects in partnership with the patient to resolve the nursing diagnosis monitor for the development of a risk problem or carry out physician orders

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Physician prescribe interventions

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Are those actions ordered by a physician for nurse or other health-care professional to perform remember that physician orders are not orders for nurses but prescriptive instructions for patients nursing judgment must still be used LVN must follow orders when administering medications performing wound care in ordering diagnostic test

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Nursing prescribe interventions

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Any actions that a nurse is legally able to order or begin independently nurses right interventions for themselves or other nursing staff

Example of independent nursing interventions are providing a back massage turning a patient every 2 hours monitoring for complications

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Temperatures

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Normal body temperature 97. Fahrenheit - 99.6 Fahrenheit core temperature which is temperature of deep tissues of the body surface temperature was his temperature of the skin

It's patient drink hot or cold drinks you have to wait 30 minutes before taking temperature

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Auscultate

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Listen for sounds within the body to evaluate the condition heart lungs pleura intestines and other organs or detect fetal heart tones

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Tachycardia

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Pulse that is faster than 100 beats per minute

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Bradycardia

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Beats that are slower than 60 beats per minute

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Dysrhythmia

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Any disturbance or abnormality in a normal rhythmic pattern specifically irregularity and normal Rhythm of the heart

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Pulse sites

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Temporal (temples)

Carotid (neck)

Brachial (inner elbow)

Radial (inner thumb side wrist)

Femoral (inner pelvic area)

Popliteal (behind knee)

Posterior tibial (back foot near ankle)

Dorsalis pedis (top of foot)

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Apical pulse

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Represents the actual beating of the heart

Most accurate

Auscultation (listening with stethoscope) of the apical rate is essential on all cardiac patients and when radial pulse is irregular or difficult to palpate or when certain medications

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Factors that influence pulse

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Age exercise fever pain anxiety severe pain chronic pain medications

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Pulse deficit

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Difference is found between radial and apical rates it's confirmed by one nurse listening to the apical rate and second nurse palpitating the radial pulse at the same time using the same watch for one full minute a deficit exists when the radial rate is less than the apical rate

Signifies that the pumping action of the heart is faulty and there is a preferable vascular tissue often seen in atrial fibrillation

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Internal respiration

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Refers to the exchange of gas at the tissue level caused by process of cellular oxidation and the gas exchange that occurs and the alveoli of the lungs

Men have greater lung capacity than women

Opiates pain medication slows respirations

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External respiration

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The cycle of external respiration has two parts

Inspiration and expiration inspiration is inhaling air with oxygen into the lungs and expiration is exhaling air with carbon dioxide out of the lungs controlled by the medulla oblongata in the brain

Normal respiration id 500 mL

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Tachypenia

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Rapid respiratory rate

In assessing respirations note the rate the depth the quality and the Rhythm

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Bradypnea

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Slow respiratory rate below 10

per min

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Dyspnea

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Breathing with difficulty

The patient may be laboring to get enough oxygen with pierced pursed lips flared nostrils and clavicle and costal retractions

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Cheyne-stokes respiration

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Abnormal pattern of respiration characterized by alternating periods of apnea and deep rapid breathing

are noted in the critically or terminally ill patient

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Factors that influence respiration

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Disease or illness stress fever age gender body position medication exercise acute pain smoking brain stem injury hemoglobin function

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Blood pressure

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The pressure exerted by the circulating volume of Blood on the atrial walls the veins and the chambers of the heart blood pressure is measured in millimeters of mercury (mm Hg)

Blood pressure reflects cardiac output the amount of blood discharge from the left or right ventricle per minute the quality of the arteries the blood volume and the blood viscosity

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Systolic

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Pressure is higher number and represents the ventricles Contracting forcing blood into the aorta and the pulmonary veins

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Diastolic

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Lower number of the blood pressure represents the pressure within the artery between beats that is between contractions of the Atria or the ventricles when blood enters the relaxed Chambers from the systemic circulation in the lungs

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Pre hypertension

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Values 120-139/80-89

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Hypertension

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140/90

Risk factors include family history of hypertension obesity smoking heavy alcohol consumption elevated blood cholesterol level and continued exposure to stress

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Hypotension

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Blood pressure below normal a low blood pressure is considered healthy provided there is no ill effects such as vertigo or syncope fainting

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Orthostatic hypotension

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Drop of pressure when a person moves from lying to sitting or from sitting to standing position occurs when a person Rises too quickly usually from supine Laying position patient feels light headed in light-headed and unstable advise patient to rise slowly from lying to sitting to standing

They are a at fall risk patient

Educate to not rise too quickly and to take their time when walking

Anti seizures medication blood pressure medication and antipsychotic medication can cause symptoms

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Conditions that cause alterations in blood pressure

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Hemorrhage increased intracranial pressure acute pain end-stage renal disease primary essential hypertension general anesthesia exercise postural change smoking

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Pulse oxygen

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98% normal above 95%

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A D O P I E

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Assessment

diagnosis

Outcomes

planning

implementing

evaluation

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Assessment

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Nurse collects data

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Diagnosis

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Nurse analyzes data in determining diagnosis

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Outcome

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Identification nurse identifies expected outcomes

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Planning

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Nurse develops a plan of care

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Implementation

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Nurse implements interventions identified and plan

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Evaluation

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Nurse evaluates clients progress

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SBAR

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Situation background assessment and recommendation is a method of communication among healthcare workers and part of documentation measure and preventing errors from a poor communication during handoff or hand over interactions the communication that occurs from one shift to the next or when a nurse phones a healthcare provider with information about the patient

when sbar occurs between nurse and health care provider over the phone and order it received from the healthcare provider and additional are is added the r represents read back when the nurse reads back the order for clarification

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Excudate

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Refers to fluid cells or other substance that are slowly excuted or discharge from cells or blood vessels through small pores or breaks and cell membranes usually a result of inflammation or injury perspiration pus and serum or sometimes identified as excudates

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Symptoms

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Are subjective indication of illness that the patient perceives examples of symptoms or pain nausea vertigo pruritus diplopia numbness and anxiety the subject data or what the patient the scribes related to pain nausea and others

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Subjective data

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Collection the interviewer in Courage as a full description by the patient of the onset the course and the character of the problem at any factors that aggravate or alleviate it

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Pruritus

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Itching

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Etiology

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Unkown cause

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Hereditary

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Diseases are transmitted genetically from parents to children

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Congenital

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Disease appear at birth or shortly there after but are not caused by genetic abnormalities

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Inflammatory

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Diseases are those in which the body reacts with an inflammatory response to some causative agent.

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Degenerative

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Disease implies degeneration often progressive of some part of the body

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Infectious

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Diseases result from the invasion of microorganisms into the body

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Deficiency

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Diseases result from the lack of specific nutrient. Minerals vitamin proteins fats and carbs

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Metabolic disease

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Caused by dysfunction that results in a loss of metabolic control of homeostasis in the bosy

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Neoplastic diseases

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Abnormal growth of new tissues

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Traumatic conditions

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Result from both physical and emotional trauma

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Environmental disease

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Are a group of conditions that develop from exposure to a harmful substance in environment

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Signs of infection and inflammation

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Erythema redness

edema swelling

heat

pain

purulent drainage pus

a loss of function

Inflammation is protective response of body tissues to irritation injury

Invasion by disease producing organisms the inflammatory response is actually the body's defense against some causative agent

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Physical assessment techniques

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Inspection or purposeful observation is the technique that nurse uses most frequently visually inspect the patient's body and observe moods including all responses and nonverbal behaviors

Palpitation the nurse uses the hands and sense of touch together data they hands are highly sensitive to texture temperature and moisture and help determine the quality of an area use palpitation to detect tenderness temperature texture vibration pulsations masses and other changes in the structural integrity

Auscultation is the process of listening to The Sounds produced by the body the cardiovascular system respiratory system and gastrointestinal system

Percussion is used of the fingertips to tap the body surface to produce vibration and sounds the sounds indicate the density of the underlying tissue and help the nurse detect location of body organs structures

structures

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O P Q R S T U V

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Onset timing

Precipitating provocative palliative

Quanity quality

Region radiation

Severity scale

Treatments

Understanding

Values

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R O S

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Review of systems systematic method for collecting data on all body symptoms

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Kardex/rand

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A card system used to consolidate patient orders and care needs in centralized concise way

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P O M R

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Problem oriented medical record

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SOAPIER

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Subjective

Objectice

Assessment

Plan

Intervention

Evaluation

Revision