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41 Cards in this Set

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what are the 4 components to the nursing process.
******************************
establish diagnosis
develope outcome goals
plan interventions
document the nursing plan of care
the deal here is the establishing of priorities. in the real world, the pt might have 20 problems, so we ...
try and come up with a plan to fix some of the major problmens
we would use to establish priorities:
physiologicial importance
rank needs w/ pt and family
what else?
use maslov's hiearchy of needs
basic needs safety, love, etc
goals have to be written well and are MEASURABLE.. if goals are well written, then...
the evaluaion goes well too, but if its vague, you can't tell if you had met your goals.
3 things to remember writing goals:
patient centered/driven
time frame
measurable
specific
short term: hous,days
lo
ng term: weeks, days after discharge
Goals must be:
observable
singular
realistic for patient and nurse
what else?
measurable: can tell when it has happened
reflects highest level of wellness
Clear, specific goals include:
the subject
Action verb
condition
criteria
time lapse
the VERB:
is an action verb
is measurable
what words do you not use?
normal
acceptable
sufficient
adequate
improved
the verb must be objective
The next part of defining the goal is the condition. say things like:
under what condition
provide clarity
condition with which the activiity must be performed
what else is ex of condition
with use of walker
using diet plan left by dietican
not essential, but does help clarify
the next part of the goal concept is CRITERIA
examples are:
time limit or time line
amount of activity
description of performance
how well it is to be done

examples?
ambulate 10 feet
list 3 signs of infection
the VERB:
is an action verb
is measurable
what words do you not use?
normal
acceptable
sufficient
adequate
improved
the verb must be objective
The next part of defining the goal is the condition. say things like:
under what condition
provide clarity
condition with which the activiity must be performed
what else is ex of condition
with use of walker
using diet plan left by dietican
not essential, but does help clarify
the next part of the goal concept is CRITERIA
examples are:
time limit or time line
amount of activity
description of performance
how well it is to be done

examples?
ambulate 10 feet
list 3 signs of infection
Criteria is the next part of the specified goal,after condition. what is criteria about?
time limit or time line
amt of activity
description or performance
how well it is to be done
EX: ambulate 10 feet
list 3 signs of infection
then the goal has to have a time line:
"by the end of the shift"
"by discharge"
lets look at this:
subject = the patient
verb = will walk
condition = with use of cane
criteria = to the door and back to bed
time frame = by friday 11/01/06
here's something Karla read outloud
"the patient will know the 4 basic food groups by the end of the shift" is this good?
How about this one
"Mr Brown will feel less pain by the end of the shift"
3 domains for goals

cognitive
phychomotor
affective. which 2 will we be writting in ?
congnitive and phychomotor

Psychomotor deals w/ developing motor skills
"will demonstrate"
"will correctly perform"
"will ambulate"
"will draw up medication"
what does affective domain have to do with?
associated w/ changes in attitudes, feelings, or values
REAL hard to measure!
Novices shouldn't go here!
so b/c associative is difficult to measure, we will stick to cognitive and psycomotor domains. what are examples again of cognitive and phschomotor goals?
"will explain"
"will state, will identify"
psychomotor is like
"will demonstrate"
"will perform"
"will ambulate"
How about some AFFECTIVE domain words!!!
express
share
listen
communicate
relate. what is it hard for these words to do?
to measure
"Pt will list risk factors for heart disease? good or bad? i think she said bad. flip has it better
the pt. will list 4 risk factors for heart disease by friday
how about "the patient will be turned every 2 hours. like it?
how about "the pt will identify 4 signs of infection by discharge" Its good!
"the patient will know 4 sources of protein by the end of the shift" better way?
"the pt will list or identify 4 sources of protein by the end of the shift"
so b/c associative is difficult to measure, we will stick to cognitive and psycomotor domains. what are examples again of cognitive and phschomotor goals?
"will explain"
"will state, will identify"
psychomotor is like
"will demonstrate"
"will perform"
"will ambulate"
How about some AFFECTIVE domain words!!!
express
share
listen
communicate
relate. what is it hard for these words to do?
to measure
"Pt will list risk factors for heart disease? good or bad? i think she said bad. flip has it better
the pt. will list 4 risk factors for heart disease by friday
how about "the patient will be turned every 2 hours. like it?
how about "the pt will identify 4 signs of infection by discharge" Its good!
"the patient will know 4 sources of protein by the end of the shift" better way?
"the pt will list or identify 4 sources of protein by the end of the shift"
so b/c associative is difficult to measure, we will stick to cognitive and psycomotor domains. what are examples again of cognitive and phschomotor goals?
"will explain"
"will state, will identify"
psychomotor is like
"will demonstrate"
"will perform"
"will ambulate"
How about some AFFECTIVE domain words!!!
express
share
listen
communicate
relate. what is it hard for these words to do?
to measure
"Pt will list risk factors for heart disease? good or bad? i think she said bad. flip has it better
the pt. will list 4 risk factors for heart disease by friday
how about "the patient will be turned every 2 hours. like it?
how about "the pt will identify 4 signs of infection by discharge" Its good!
"the patient will know 4 sources of protein by the end of the shift" better way?
"the pt will list or identify 4 sources of protein by the end of the shift"
stay away from vague verbs!
"knowledge deficit (disease process) r/t lack of exposure to information m/b questions about diabetes. better?
Goal:
"the pt. will understand the disease process of diabetes by Friday 11/03/05. the original goal was too big, so make it more specific
what about these goals:

risk for fluid volume deficit r/t NG tube. NPO status m/b NA
goal: client will maintain fluid vol. at a functional level as evidenced b adequate output (39 ml/hr)look at flip
write a nursing diagnosis and a goal.
ND anxiety r/t long hospital stay m/b diarrhea and incontience
Goal: pt will learn about importance of fluid intake and his disease condition
So, as review, after defining the goal, we come up with the interventions. what is an intervention?
actions done by the nurse to achieve the goals:
ASK:
will it be effective?
is it realistic for the pt?
is it realistic for the nurse?
Interventions:

are nurse driven, detailed, should tell WHAT WHEN HOW
rank in order of importance
what else?
detailed
should tell what when how
rank order of importance
which must be done first
involve the patient
Independent:
a nurse can do w/out consultation or collaboration or orders! that is indepedent. an ex follows:
EX: input and output or teaching or checking a blood gas
whats an example of interdependent intervention?
nurse collaborates w/ other disicplines
what is a dependent intervention?
requires order from another health care provider
action/interventions must be detailed so a float nurse or new nurse can follow up on the intervention and knows what the plan is. expand this
any nurse should be able to read and plan and follow it, the nursing intervention