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a. Describe the 5 Phases of the Nursing Process (Review Ch. 10, pg.215, Table 10-2 for a visual)
- Step 1: Assess
- a. Collection, validation, and communication of patient data
- a. Subjective: What the patient tells you (usually verbal)
- b. Objective: What you notice (physical assessment, vitals)
- b. Ask open-ended questions
- Step 2: Diagnose
- 1. Analysis of patient data to identify patient strengths and health problems that independent nursing intervention can prevent or resolve
- 2. Develop a prioritized list of nursing diagnosis
- 3. This process of thinking is known as:
- Clinical Reasoning: the ability to think through a clinical situation as it changes while taking into account what’s important to the family and client
- * Three Part Diagnostic Statement
- P: Problem—The nursing diagnosis label. ex: Insomnia
- E: Etiology —Related to phrase (r/t) ex: r/t stress, anxiety
- S: Symptoms—Difficulty falling asleep. ex: “I can’t sleep”
- Step 3: Planning (Plan of Care)
- 1. Identifying priorities and determining of client-specific outcomes and interventions
- 2. Patient outcomes to prevent, reduce or resolve the problems identified by the nursing diagnosis
- Symptom Pattern Recognition: the process of identifying symptoms the client has related to their illness.
- 1. Understanding which pattern symptom requires intervention
- 2. And the associated timeframe to intervene effectively
- 3. The highest priority should be done by, ABC
- A. Airway
- B. Breathing
- C. Circulation
- 1. Example: Anxiety
- a. Outcomes: anxiety self control, anxiety level, coping
- b. Interventions: anxiety reduction
- c. Rationale: use empathy to interpret, encourage client to use positive self-talk
- Step 4: Implementing (carrying out of plan)
- 1. Carrying out of jointly accepted interventions focused on:
- 2. Symptom Management: alleviating symptoms
- 3. Perform interventions individualized to client
- Step 5: Evaluation
- 1. Reassessing where the client was (baseline), and where the client is following intervention
- Use SMART—Interpretation of Interventions
- S: Specific
- M: Measureable
- A: Attainable
- R: Realistic
- T: Time
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2. Examine the relationships among the phases of nursing process
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c. Organize Assessment cues relative to each other (247)
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d. Formulate Nursing Diagnosis Statements appropriate to the client’s priority needs.
- Three Part Diagnostic Statement
- P: Problem—The nursing diagnosis label. ex: Insomnia
- E: Etiology —Related to phrase (r/t) ex: r/t stress, anxiety
- S: Symptoms—Difficulty falling asleep. ex: “I can’t sleep”
- Example: Elderly Man with COPD
- P: Activity Intolerance
- E: Related to (r/t) imbalance between oxygen supply and demand
- S: Verbal report of fatigue, dyspnea (difficulty breathing during walk)
- Statement:
- Activity Intolerance r/t imbalance between oxygen supply and demand web verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response to activity.
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e. Discuss the role Assessment plays in Prioritizing care (239)
- • A careful review of the patient’s record before interviewing
- Assessment Priorities are influenced by
- 1. Health Orientation
- 2. To explore their daily habits and behaviors and actual health risks that influence their wellness
- 3. Developmental Stage
- 4. Sleep Patterns
- 5. Weight gain
- 6. Physical Growth
- 7. Culture (racial, ethnic, religious)
- 8. Shaking Hands
- 9. Making Eye Contact
- 10. Need for Nursing
- 11. The duration interaction (Same day surgery)
- 12. Nature of nursing care needed (Birth delivery)
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g. Discriminate among severities of client needs using Maslow’s Hierarchy of Needs.
- Patient needs may be prioritized according to the following hierarchy:
- 1. Physiologic needs
- 2. Safety needs
- 3. Love and belonging needs
- 4. Self-esteem needs
- 5. Self-actualization needs
- Depending on the condition the patient has, one must be able to know how severe a symptom is and prioritize using the hierarchy of needs.
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k. Apply the factors necessary to support successful prioritization of care and responsibilities. Given a patient situation, state the problem. (Ch. 13, pp. 281-282)
- 3 guides to help facilitate clinical reasoning and prioritizing of needs
- a. Maslow's hierarchy of needs
- 1. Physiologic needs: Needs that help the body function properly
- 2. Safety needs: What around the environment can hurt the patient
- 3. Love and Belonging needs
- 4. Self-esteem needs
- 5. Self-actualization needs
- b. Patient Preference
- 1. As a nurse attempt to meet the needs of the patient as long as this order does NOT INTEREFERE with other vital therapies
- c. Anticipation of problems
- 1. Nurses must use their own knowledge in order to consider the potential effects of nursing actions
- a. Example: An obese patient who sees no need to change diet, nor move around in bed should be viewed as a high priority risk of pressure ulcers. Regardless of what the patient says or really wants, you must incorporate weight management and position changes into the plan of care
- d. Establishing Priorities
- 1. What problems need immediate attention and which ones can wait?
- 2. Which problems are your responsibility and which do you need to refer to someone else
- 3. Which problems can be dealt using standard plans (e.g. critical paths, standards of care)
- 4. Which problems are not covered by protocols or standard plans but must be addressed to ensure a safe hospital stay and timely discharge (safe care of high quality)
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