nursing process

  1. medicine
    • ID: drug
    • FXN: therapeutic response
  2. 7 rights
    • drug
    • dose
    • documentation
    • patient
    • route
    • reason
    • time
  3. medication order
    • drug (generic or brand name)
    • dose
    • route
    • frequency
    • date&time
    • signed
  4. nursing process
    • assess 
    • NurDx
    • goal
    • intervention
    • rationale
    • evaluation
  5. assess
    • objective
    • ex: patient's story
    • subjective
    • ex: history, lab tests
    • on-going
    • ex: admission to discharge
  6. from assess to NurDx?
    analyze
  7. History
    • analyze
    • patient 
    • family 
    • records
  8. primary Hx
    • assess
    • patient
  9. secondary Hx
    • assess
    • family
  10. tertiary Hx
    • assess
    • records
  11. what is foundation of practice for nursing?




    E. nursing process
  12. Rn  admits elderly client w/ medical diagnosis of dehydration.  In developing the nursing diagnosis it is most important for Rn to 



    A. include actual and risk for in NurDx
  13. how does MedDx differ from NurDx?



    B.  NurDx evaluates patient's response to actual or potential health problems
  14. which situation equals independent nursing action?



    D. Rn calld Md and verifies route of admin
  15. which piece of patient assessment is subjective?



    B. Pt states "I have pain in my abdomen"
  16. comprehensive data
    • assess
    • physical exam
    • patient history
    • medication history
    • professional observation
  17. Nursing Diagnosis
    • diagnostic label
    • defining characteristics
    • related to
  18. diagnostic label
    C.A.R.H.
    • NurDx
    • clinical judgement
    • about individual, family, or community
    • response to actual or potential 
    • health problems
  19. defining characteristics
    • NurDx
    • signs
    • symptoms
  20. related to
    • NurDx
    • condition
    • situation
  21. types of Nursing Diagnosis
    • actual 
    • risk for
  22. actual
    • NurDx
    • patient response to condition, situation
  23. risk for
    • NurDx
    • more susceptible to a particular problem
  24. NurDx vs. MedDx
    • NurDx: patient response
    • actual/potential 
    • health problems

    • MedDx: disease/disorder
    • impairs
    • physiological fxn
  25. Planning
    • goal
    • intervention
  26. goal
    expected outcome
  27. expected outcome
    P.M.T.
    • patient centered
    • measurable
    • time frame
    • ex: patient will demo
    • safe self-injection 3x
    • by end of shift
  28. intervention
    actions to achieve goal
  29. Rationale
    why these specific interventions?
  30. implentation intervention
    • dependent action
    • interdependent action
    • independent action
  31. dependent action
    perform by Rn per Md orders
  32. interdependent action
    cooperate as team
  33. independent action
    Rn action based on virtue of eduction and licence
  34. considerations in implementation 
    • physical needs
    • patient safety
    • potential complications
    • changes in patient's needs
  35. evaluation
    • goal met?
    • feedback?
    • effectiveness?
    • changes?
  36. goal met?
    • evaluation
    • met? 
    • not met?
    • partially met?
  37. feedback
    • evaluation
    • patient
    • family
    • significant other
  38. effectiveness
    • evaluation
    • what worked?
    • didn't work?
    • why?
  39. changes
    • evaluation
    • intervention adaptations
    • help achieve goal
Author
BodeS
ID
304299
Card Set
nursing process
Description
medicine administration, therapeutic response
Updated