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Characteristics of nursing process
- 1. Systematic
- 2. Dynamic
- 3. Interpersonal
- 4. Outcomes orientated
- 5. Universally applicable
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Nursing Process: 5 key steps
- 1. Assessing
- 2. Diagnosing
- 3. Outcome identification and planning
- 4. Implementing
- 5. Evaluating
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Assessment
- Collect patient information from:
- patient
- previous shift
- MD and othe provider notes
- Family members
- Observations and measurements
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Nursing diagnosis
- Analyze patient data.
- Identify health problems that independent nursing interventions can prevent or resolve
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Outcomes identification and planning
- Individualize outcomes/goals for each nursing diagnosis
- Develop with patient and family input
- Ongoing (changes as patient status changes)
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Implementing interventions or plan of care
- Nursing interventions are performed
- AND all interventions are documented
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Evaluating
Met, not met, partially met
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Outcome
usually opposite of nursing diagnosis
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Kardex
- synopsis of all patient orders
- started at admission
- written in pencil
- not part of medical record
- updated when new orders are written/every shift when there is a change
- meds are usually listed separately
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Types of assessment
- comprehensive
- focused
- emergency
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Cues
- Part of assessment
- subjective and objective data which are identified
- may indicate that something is wrong
- denotes "significant data"
- deviates from standard or norm
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inference
- part of assessment
- judgement you reach about the cues
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NANDA
- North American Nursing Diagnosis Assoc International
- Nursing dx are not developed by NANDA
- Review submissions for new dx, or revisions to existing ones or deletions
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Nursing (ANA's definition)
the diagnosis and treatment of human response to actual or potential health problems
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Types of nursing diagnoses
- Actual
- Risk
- Possible
- Wellness
- Syndrome
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Parts of a nursing diagnosis
- Problem (diagnostic label, alphabetized in list)
- Etiology
- Defining characteristics (major and minor signs/symptoms)
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Actual Diagnosis
- Problem
- Etiologoy
- Signs and symptoms
- Nursing diagnosis (response to an illness)
- Related to (something that the nurse can fix)
- As evidenced by (proof or supporting assessment data)
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Risk for Dx
- 2 parts (no "AEB")
- Risk for "problem" related to ( )
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Goal vs outcome
- Goal=big picture, an aim, an end; opposite of nursing diagnosis (e.g., patient will no longer be constipated)
- Outcome=results achieved, more specific, measurable criteria (e.g., pt will have at least one soft formed stool within 8 hrs of taking laxative)
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Goals: long vs short
- long term: usually more than one week
- short term: hours or days
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Criteria for goals/outcomes
- patient-centered
- time-limited
- measurable
- realistic
- relates directly to problem statement
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Cognitive outcomes
- Describes increase in patient knowledge or intellectual behaviors
- Patient will list
- Patient will state
- Patient will demonstrate
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Psychomotor outcomes
- Describes patient achievement of new skills
- By 10/22/11, the patient will correctly demonstrate application of wet-to-dry dressing...
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Affective outcomes
- Describe changes in patient values, beliefs, and attitudes
- By 10/3/11, the patient will verbalize valuing health sufficiently to practice new health behaviors..
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Implementation: Purpose
- Assist pt to achieve valued health outcomes
- Promote health
- Prevent disease and illness
- Restore health
- Facilitate coping with altered functioning
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Maslow's hierarchy of human needs
- Physilogic
- Safety
- Love and belonging
- self-esteem
- self-actualization
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Types of interventions
- Independent: No MD order required (e.g., turning patient every two hours to avoid pressure ulcers)
- Dependent: carrying out MD-prescribed order (e.g., administering an injection)
- Interdependent: actions performed jointly by nurses and other healthcare team members
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Evaluation
- Measure how well patient achieved desired outcome
- Modify plan of care if indicated
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Possible results of evaluation
- Terminate plan of care when outcomes achieved
- Modify plan of care if outcomes not achieved
- Continue plan of care if more time needed to achieve outcomes
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SBAR + R
- Used for shift handoff and to communicate with MD
- Situation: what's happening right now
- Background: what is key clinical background leading up to this event
- Assessment: what do you think might be going on (your analysiss)
- Recommendation: What do you want done?
- Response: What the MD/NP/PA will do. Agree on a what is to be done
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Incident report
- Documents anything out of ordinary that causes harm to patient, staff or visitor
- Do not put in medical record that an incident report was done
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Change of shift report
- Summary of what
- happened to patient during shift, what needs to be done
- ◦Pending
- tests, results of test
- ◦Reports
- of pain and last pain med given
- ◦Any
- meds or tx not given
- ◦Any
- wounds / dressings
- ◦Mental
- status
- ◦Fall
- status
- ◦Poss.
- discharge
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Charge nurse report
- How
- many patients on floor
- ◦How
- many staff members and designations
- ◦How
- many expected admissions/discharges
- ◦Number
- of isolation rooms
- Number of
- DNR patients
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Patient medical record
- Legal document
- confidential
- permanent record of care received by patient
- info recorded by several disciplines
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Late entry
Someone else charted ahead of you
- 10/06/09 pt. A&O
- x3 . O2 at 3 l/m per NC. Chest CTA. N.
- Nurse, RN
0730 Late entry
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