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54 Cards in this Set

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what was wrong with the old nursing care situation? there was no organization. one nurse would do one thing and another nurse would do another. So they developed what?
the nursing process
what was the nursing process based on
a medical model. so the cure became the process. Lydia Hall termed the term Nursing Process in 1955. It was a 3 step process. Idea borrowed from the corporate world.
in 1966 Virginia Henderson identified the nursing process as a scientific process and made nursing what?
more credible
in 1967 a 4 step process was proposed. assessment, planning, intervention, evaluation. not on the test
1973 ANA published the standard of clinical nursing practice which included what?
the nursing process. the ANA endorsed the nursing process
the NCLEX was revised in 1982 to include what?
the nursing process concept and so today the whole NCLEX is based on the nursing process and its REALLY IMPORTANT B/C the whole NCLEZX test is based on it
in 1984 JCAHO did what?
required the use of the nursing process . JCAHO is the equivilant of hospital accridition process. so for the hospital to get medicare funding, it had to be JCAHO approved, and the JCAHO was working from the nursing process model!
What is JCAHO ?
a huge thing. They sneek into hospitals and pretend to be patients and observe/rate a hospital on its care. Joint Commission of Association of Hospital Organizations. They accredite Medicare. The bottom line is money. A huge % of patients are elderly.
what was the difference in hospitals that used the nursing process as compared to those that didn't?
hospitals that used the nursing process showed the outcome was much better, they saw the difference so whenever money is involved, people conform so all the hospitals conformed.
what is the nursing process anyway?
**************************
a systematic problem solving approach.
a method for delivery of patient care
Dynamic (easy to mold to each patient)
Flexible
Creative
What is the purpose of the nursing process?
identifys health care needs
establishes patient goals
determines priorities
establishes a plan of care
provides nursing interventions
evaluates effectiveness
What is a process anyway?
a series of events

one event leads to another

all events work toward the goal achievement
what are the 5 steps of the nursing process again?
a a p I e
assessment
analysis
planning
implentation
evaluation
So assessment is #1 to establish a database from a physical assessment. this is why we are studying what now?
the physical assessment!
its the first part of the nursing process.
part of this is questions asked at admission like what meds are you on? what is your medical history? why are you here today? where do you hurt? where else do we get informtation?
old medical records
from the lab diagnostic exam
other medical team members
the patient themselves
what the family says
the physical exam will include inspection
palpations
percussion (we won't do this)
ascultation.
so we get alot of information through a physical exam. how else do we get information?
verbally.
we use communication skills to establish a relationship to get information. these are personal questions so you have to develope a repore and can't act like your in a hurry and don't care what they say. so don't look at your watch, not making eye contact, watch your non verbal signals you are sending out in order to develope a repore.
What is a process anyway?
a series of events

one event leads to another

all events work toward the goal achievement
what are the 5 steps of the nursing process again?
a a p I e
assessment
analysis
planning
implentation
evaluation
So assessment is #1 to establish a database from a physical assessment. this is why we are studying what now?
the physical assessment!
its the first part of the nursing process.
part of this is questions asked at admission like what meds are you on? what is your medical history? why are you here today? where do you hurt? where else do we get informtation?
old medical records
from the lab diagnostic exam
other medical team members
the patient themselves
what the family says
the physical exam will include inspection
palpations
percussion (we won't do this)
ascultation.
so we get alot of information through a physical exam. how else do we get information?
verbally.
we use communication skills to establish a relationship to get information. these are personal questions so you have to develope a repore and can't act like your in a hurry and don't care what they say. so don't look at your watch, not making eye contact, watch your non verbal signals you are sending out in order to develope a repore.
The lab diagnostic results will provide huge amounts of information. How?
verify knowledge we already have
suggest new findings. Lab results are a great source for assessment information.
Another source of information for the assessment is through other team members. how?
shift to shift nurse meetings.
get a new slant on it
this requires good communication skills
the family is a great source of information for assessments. Medications, mobility, reality checks. but what does this require?
good communication skills
Medical records can provide what for the assessment process?
past hospitalizations
past medical historys
past surgeries, past allergies
the condition of the patient before treatments. Most all old records from a hospital are pulled and sent to the floor for eveyone's use.
Data Collection, stuff that will go into a record, we can't what?
make interpretive statements
You can describe what you see like there is a scar on the abdomen, don't say there is an a ppendectomy scar on his abdomen because we are guessing aren't we. SO, JUST DESCRIBE WHAT YOU SEE AND THAT S ALL
there are different types of data. subjective and objective.
********************************
what is the difference?
subjective is what patient tells us, what pain is like, nausia
objective is like lab results.
we need to be able to identify the difference b/t subjective and objective data.
pain description is subjective. we can't see pain.
nausia is something you cannot see or feel. subjective is something the patient can tell us that we cannot see, observe. Objective is information that is concret.
what is the whole point to this discussion of subjectiv/objective data gathering?
it has to do with how we report information to others and on paper. We would have to write "The patient states that blah blah." You have to say it that way b/c the information is subjective. I did not see pain, I did not see nausia. No one can see pain.
Measured amounts of vomit would be subjective? objective?
objective b/c you would measure it. you would never estimate in a report. Don't say the patient threw up about a cup into the toliet. I think this is what Karla said
Now we move to Analysis of the Nursing Process, part 2 of the medical model. What is Analysis?
how we describe a patient's actual or portential response to health problems (what the nurse is liscenced & competent to treat.)
This part of the discussion brings up the concept of Nursing Diagnosis. Very different from ...
medical diagnosis. the two are very different.
what is the purpose of the nursing diagnosis?
the purpose of the nursing diagnosis is to:
analyze the data,
identify the problems,
provide direction for the care plan.
what is the evolution of this concept diagnosis?
only MDs could diagnosis. But after 1980s doctors couldn't get over this concept of nursing diagnosis. but JCAHO mandated it and it became policy then.
the nursing diagnosis is very different from medical diagnosis. 1973 group didn't have a name but it became what?
NANDA. North American Nursing Organization Association. formed in 1982. In both of my medical books there is a NANDA list in there. Karla suggest we find and look at these lists.
what are these NANDA lists? what do they contain?
a list of all the accepted nursing diagnosis at present.
******************************
So when you hear the term NANDA, we are talking about a list of all the accepted nursing diagnosis.
There are medical diagnoses and nursing diagnoses. One is done by the doctor and the other by the nurse. The medical diagnoses indicates a disease. What does the nurse diagnose do?
indicates the response to the disease.
********************************
The physician's diagnosis remains constant until recovery. Give an example of this
Ex the diagnosis is pneumonia until its gone.
the nursing diagnoses for pneumonia can change, remember, nursing diagnosis is a RESPONSES to the medical diagnosis.
Ok, the guy has pneumonia. He's in bed all the time. The nursing diagnosis is he's at risk for skin breakdown b/c they are in bed all the time. So the nursing diagnosis is
risk for impaired skin integrity. This is a nurse diagnosis. Maybe the COPD needs rests b/t activities so the nursing diagnosis is rest b/t activities because 90% of what nurses do is teach. Looking at how the patient responds to disease.
there is a 3 part format to a nursing diagnosis.what is it?
diagnostic statement
related factors
as manifested by
so the diagnostic statement, the first part of the diagnosis format is the ...
diagnostic statement, the problem.
Ex "impared skin disease"
related to what? related to immobility (bedridden) manifested by an open ulcer on the bottom.
after making the big diagnostic statement you then add the related factors. what is this?
the cause or causes. As manifested by blah blah.
Step 3 of the nursing process is ?
Planning

we have done the assessment, gather the data, and the nursing diagnosis. Out of the 3 we have established a priority. This is where Maslov's law comes in. This is what planning is about.
Planning is goals and outcomes.
what is a goal? An objective to work towards. Without the goal, we don't know where we are going or if any of our work is effective.
a specific statement of patient behavior or response. we have to have a goal in order to know what to work to. It shows if the interventions are effective. BECAUSE when it comes time to evaluate the care, you have to ask, "Was that goat achieved?" Goals are always patient driven. Goals will say "The patient blah....
They have to be specific and measurable.
A goal has to be specific and measurable and a ....
time frame. have to be able to tell if the goal has happened.
Let have a game called patient goals and see if they are patient driven, specific, etc.
how they are written.
"The patient's goal are to list the risks of hypertension by discharge."
its patient driven
is there a time line?
its good but is missing is how many risk factors they risk.
so is 1 enough or 4 risks to teach.
has to have a time line
has to be patient driven
has to be measurable.
After we establish the goals we have the what?
the interventions
actions to take us where the goal is achieved. so after we establish our goals, we will come up with who, when , how we will go toward achieving the goals for the patient.
so interventions are?
selected after goals are established and are actions to accomplish the established goals. They are nurse driven and indicate who what when how. MUST be specific!
Step 4 of the nursing process is IMPLEMENTATION. Putting the plan into action. This is where we might have to delegate this plan to who?
who ever has the skills to get the plan to work. Are they competent to do the work we deligate to others?
the other part to implementation is to continue to ..
reassess the patient's condition to make sure these interventions are still appropiate. Remember the patient's condition is dynamic. their condition can change.
Last step is Evaluation. Did our plan work? were the goals met? what do we do now? If we met our goals then what do we do now? Or are goals partially met?
any progress?
no progress?
not totally there?
So, then is the diagnosis correct?
Ex. of not meeting a goal when we evaluate our care plan to meet the patients goal of gaining weight. We immlemented a plan of action based on the goals to gain weight, but it didn't work. Why?
the evaluation was that the patient didn't eat the food in the implementation because his dentures didn't fit right and had sores on his gums so it hurt to eat. And we missed that in the planning phase. So, our manifest (which tells why we have a problem) stated the lack of weight gain was lack of nutritious food, but we found out he couldn't gain weight b/c of poorly fitted dentures and a sore mouth. So we regroup, and so our interventions will be totally different, interventions will be new dentures, fix the sores in the mouth, etc.
the nursing care plan is what we come up with using the nursing process. to develop the care plan. a written diagnosis, evaluation, implementation and evaluation. it does several different things.
it decreases risk of bad care
etc.
whats the average hospital stay? 3 days so we don't have time to do what we need to do so we teach, especially for out patient care so they know ...
how to take care of themselves so they know to call if they have problems.
This approach of care plans helps for everyone, float nurses, anyone that gets involved knows what is going on. ..
to keep on tract what we are suppose to be doing, the goals, the teaching we will do, so on the third day on discharge, they're ready to go.