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31 Cards in this Set

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nursing used to be by the seat of the pants. each nurse doing their own thing. pre 1955 patient care was based on ...
MD orders
what person in 1955 coined the term nursing process?
Lydia Hall
1959-1063 a 3 step process was introduced. . who introduced the nursing process as a scientific model in 1966?
Virginia Henderson

think Virginia Slims
in 1967 a 4 step process was proposed. assessment, planning, intervention, and evaluation. what happened in 1973 by the ANA?
published standards of clinical nursing practice
1982 the nclex was revised. what happened?
it included nursing process concepts
in 1984, jacho required what?
the use of the nursing process
jacho assess and evaluated hospitals on their quality of care, infection control, for certification for medicare payments.
what is the purpose of the nursing process?
id the health problem/care needs
establish patient goals
determine priorities
establish nursing interventions
evaluate effectiveness
what is a process?
a series of events
one event leads to another
all events work toward a goal achievement
there are 5 steps in nursing process? assesssment, anaylsis, planning, impemenet, evaluation
how do you assess?
physical assessment
health history
lab/diagnostic exams
team members
medical records
patient themselves
family too
so the physical assessment part
what happens here?
inspection
palpation
percussion
auscultation
what happens with the health history part of the assesssment?
establish a relationship
communication skills are needed
verbal and nonverbal
the lab results help the physical assessment too. how?
verify knowlege
it is objective information
suggest new findings
what do we glean from the team members?
new info
a new slant
this requires good com skills
what can we pick up from the family?
meds
mobility
reality info
its all subjective but critical info
what can medical records tell us?
past hospitalizations
past medical history
how should we proceed in data collections?
be descriptive
concise
complete
NO interpretive statements
what are the types of data?
subjective and objective data
sub = what the patient says
what pain feels like
Ex. patient says they are nausea
anything we cannot see is subjectve
what is objective data?
what you see
lab results are objective
concrete data, we can see it
smell
there is the anaylsis of nursing diagnosis. This is the 2nd part after assessement. what is it?
description of patient's actual/potential response to health problems.
It purpose it to:
analysis data, id problems, provide direction for the care plan
there is an evolution to the diagnosis part of the nursing process. can you describe it?
used to be only MD could diagnose.
conference in 1973 was held to classify nursing diagnosises. yea woopie!
what is NANDA and so what?
north american nursing diagnsos ass. formed in 1982. it listed acceptable nursing diagnosis,
there is the medical diagnosis and there is the nursing diagnosis. YOU BETTER KNOW the difference. describe the MD diagnosis
determined by MD
indicates a disease
diagnosis remains same until recovery
Ex. pneumonia, COPD, renal failure
what is an example of the nursing diagnosis?
well first of all its determined by a nurse and not a doctor.
the nursing diagnosis indicates a patient's response to treatment
Ex. risk of impaired skin integrity
Ex. knowledge deficit
Ex. self care deficit
there is a 3 part format to nursing diagnosis:
diagnosis statement
related factors
what else?
problem dia. statment
cause related factors
symptoms as manifested
Then the 3rd part of the nursing process is planning. you establish priorities. how do you establish the planning priorities?
rank diagnosis in order of important
maslov's hieracrhy
basic needs
when possible, involve patient
planning has goals and outcomes right?
so what ?
what = specific statement of patient behavior response.
why? provides direction of care
shows if interventions are effective
ishow we evaluate patients response to care
then we can go back to the goal and see if it has been achieved
the goals of the planning should be:
specific and measurable
have a time frame
are patient driven
what about intervention of the nursing process? what is intervention?
selected after goals are established
what are they? actions to accomplish the goals
are nurse driven
should indicate who, what , when, and how
then the implementation of the nursing process, step 4.
what is this? the implementation?
putting the plan into action!
you do this by delegation.
who, how to decide?
by their level of education and scope of the job/practice
expertise/competence
so the internventions are continually reassess why?
to re evlauate to make sure the interventions are approapriate b/c the patient's condition could of changed.
the last step, step 5 is evaluation. did it work? what now?
we use the nursing care plan here: