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Method of caring that provides a framework for nursing practice
Nursing Practice
(it is Systematic, Patient-centered, and Goal Oriented)
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Steps to the Nursing Process
- Assessment --> systematic & continuous
- Outcome Identification and Planning-->
- Implementation
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Nurse and patient mutually identify expected outcomes and agree on nursing interventions necessary to meet these outcomes
Outcome Identification & Planning
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Nurse implements the plan of care, adapting it to each
individual and documents nursing actions and patient responses
Implementation
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Nurse and patient
Evaluate the effectiveness of the plan based on achievement of outcomes
Determine if the plan should be continued, modified, or terminated
Evaluation
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Who first used the term "nursing process"
Hall (1955)
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Who published the first comprehensive book on nursing process.
Described 4 steps: assessment, planning, intervention, evaluation
Yara and Walsh
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Who made nursing diagnosis a separate step in the process – leading to the 5 step process we use today.
Gebbie and Lavin
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Steps to Nursing Process
Assess patient to determine the need for nursing care
Determine nursing diagnoses for actual and potential health problems
Identify expected outcomes and plan care
Implement the care
Evaluate the care
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Purpose of Nursing Diagnoses
Identify how an individual, group, or community responds to actual or potential health and life processes
Identify factors that contribute to or cause health problems (etiologies)
Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems
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Types of Nursing Concerns
- *Monitoring for changes in health status
- *Promoting safety and preventing harm, detecting and controlling risks
- *Identifying an meeting learning needs
- *Tailoring treatment and medication regimens for each individual
- *Promoting comfort and managing pain
- *Promoting health and a sense of well-being
- *Recognizing and addressing problems that impede the ability to be independent and live a healthy lifestyle
- *Determining human responses
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When was nursing dx introduced as a term
1953
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ANA introduced nursing dx into professional nursing officially in
1973
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North American Nursing Diagnosis Association (NANDA) came about in
1973
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What is the primary responsibility of nursing?
- Collaborative problems
- (With collaborative problems the prescription for treatment comes from nursing, medicine, and other disciplines)
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Type of diagnosis that represents a problem validated by the presence of major defining characteristics.
Actual
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Type of diagnosis.... clinical judgments that an individual, family or community is more vulnerable to develop the problem than others in the same or similar situation.
Risk Dx
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Type of Diagnosis: ....statements describe a suspected problem of which additional data are needed. Need more information to confirm or rule out the suspected problem.
Possible Nursing Dx
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Type of Diagnosis....clinical judgments about an individual group or community in transition from a specific level of wellness to a higher level of wellness. “Readiness for enhanced…”.
Wellness Nursing Dx
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Type of Nursing Dx...a cluster of actual or risk nursing diagnoses that are predicted to be present because of a certain event or situation: “Rape-Trauma syndrome”
Syndrome Nursing Dx.
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3 Components to the Nursing Dx. Statement
- Problem
- Purpose to describe the health state or health problem
- of the patient as clearly and concisely as possible
- (Use NANDA list (p. 274-275) and available in your PDA)
- EtiologyIdentifies the physiologic, psychological, sociologic,
- spiritual and environmental factors believed to be related to the problem as either a cause or a contributing factor
The etiology directs the nursing intervention
For this semester…try NOT to use a medical diagnosis as your etiology
- Defining characteristics
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Subjective and objective data that signal the existence - of the health problem
- **Not required for a Risk for nursing diagnosis
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Problem Statements should be chosen from what list?
NANDA
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Something that is desirable, useful:
NEED
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Theory of Human Needs comes from...
Maslow's Hierarchy
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Factors that affect need satisfaction
- acute/chronic illness
- developmental stage
- self concept
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Priortization of Needs:
- Physiological Problems FIRST
- Pyschological Problems Next
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How are Oxygen Needs assessed:
- •HR
- •LOC
- •Mood
- •Pulse Ox
- •Resp. rate
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How do we assess a person's fluid status?
- Body wt
- Urine output
- Blood pressure
- Mucous Membranes
- Breath sounds
- Heart Rate, Resp. rate
- Skin turgor
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