N210 Week 2 Lab Nursing Process & Clinical Decision Making

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  1. 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
  2. 2. Examine the relationships among the phases of nursing process
  3. c. Organize Assessment cues relative to each other (247)
  4. 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.
  5. 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)
  6. 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.
  7. 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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N210 Week 2 Lab Nursing Process & Clinical Decision Making
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