-
initiating urgent intervention
you should not wait to make final diagnosis if there are signs and symptoms indicating the need for immediate treatment
-
collecting, validating and communicating patient data
assessing
-
analyze patient data to identify patient strengths and problems
diagnosing
-
specifying patient outcomes and related nursing interventions
planning
-
carrying out the plan of care
implementing
-
measuring extent to which patient achieved outcomes
evaluation
-
characteristics of the nursing process
- systemic
- dynamic
- outcome oriented
- universally applicable
-
problem solving and the nursing process
- trial and error
- scientific problem solving
- intuitive problem solving
- critical thinking: intuitive, logical or both
-
should you use clinical reasoning during assessment
yes
-
characteristics of nursing assessments
- purposeful
- prioritized
- complete
- systematic
- accurate
- relevant
- recorded in a standard manner
-
four types of nursing assessments
- initial comprehensive
- focused
- emergency ABCD
- time-lapse
-
performed shortly after admittance to hospital
performed to establish a complete database for problem identification and care planning
first time admission
initial comprehensive assessment
-
may be performed during initial assessment or as a routine ongoing data collection
performed to gather data about specific problem
focused assessment- usually acute problem
-
1. performed to compare a patient's current status to baseline data obtained earlier
2. reassess health status and make necessary revision
3. performed to collect current status data
time-elapse
-
characteristics of DATA
- purposeful
- complete
- factual and accurate
- relevant
-
four phase of nursing interview
- preparatory phase
- introduction
- working phase
- termination
-
when to verify data
when there is a discrepancy between what the person is saying and what the nurse is observing. also when data lack objectivity
-
5 steps of data interpretation and analysis
- 1. recognizing significant data: comparing data to standard
- 2. recognizing patterns or cluster
- 3. identifying strengths and problems
- 4. identifying potential complications
- 5. reaching conclusion
-
PPMP alfaro
predict, prevent, manage, promote
-
types of nursing diagnoses
- actual
- risk
- possible
- wellness
- syndrome
-
four components of a diagnosis
- label
- definition
- defining characteristics
- related factor
-
three elements of comprehensive planning
-
IOM's six aims
- safe
- effective
- efficient
- patient-centered
- timely
- equitable
-
alfaro's rule
assess, reassess, revise, record
-
four types of outcomes
- cognitive
- psychomotor
- affective
- physiologic
-
evaluative criteria vs. standards
criteria is measurable qualities, attributes or characteristics the specify skills, knowledge, or health status while standard is level of performance accepted and expected by the nursing staff
-
variables affecting outcome achievement
- patient-they give up
- nurse-they burnout
- health care system-inadequate staffing
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