Nursing Diagnosis is the __ step of the nursing process?
The second step.
A nursing diagnosis is?
A clinical judgement about the patient, family or community responses to actual or risk problems, wellness, or syndromes.
How are the medical and nursing diagnosis' different?
The medical will always stay the same, the nursing will change depending on the client's health.
What 6 things help to create a nursing diagnosis?
- 1. Looking for common patterns.
- 2. Clustering common patterns.
- 3. Using critical thinking skills, identify a possible nursing diagnosis matching the NANDA list.
- 4. Analyzing assessment data to find strengths or problem areas.
- 5. Individualized to each patient.
- 6. Directs focus.
What does PES stand for in the nursing diagnosis 3 part problem?
Problem, Etiology, & Symptoms
What does the problem mean in the PES diagnosis system?
Choosing a problem from the NANDA list
What does the etiology mean in the PES diagnosis system?
"Related to" factor. What is contributing to the problem that a nurse can legally identify and treat that is NOT a medical diagnosis
What does the Symptoms mean in the PES diagnosis system?
Signs and symptoms, or as the NANDA describes them, defining characteristics taken from assessment information.
What is the NANDA list?
North American Nursing Diagnosis Association. Labels, concise definition of the problem.
As Evidenced By Nursing is?
2-3 signs or symptoms gathered during the assessment phase. Defining signs and symptoms.
What 5 steps is in Maslow's Hierarchy of needs most important to least?
- 1. Physiological Needs
- 2. Safety Needs
- 3. Love needs
- 4. Esteem needs
- 5. Self-Actualization Needs
What does the Physiological Needs in Maslow's Hierarchy mean?
Basic needs. Need for air, nutrition, water, elimination, Rest, and Thermoregulation, Ect.
What does the Safety Needs in Maslow's Hierarchy mean?
Need for shelter and freedom from harm and danger
What does the Love Needs in Maslow's Hierarchy mean?
Need for affection, feelings of belongingness and meaningful relations with others.
What does the Esteem Needs in Maslow's Hierarchy mean?
Need to be well thought of by oneself as well as by others.
What does the Self-Actualization Needs in Maslow's Hierarchy mean?
Need to be self-fulfilled, learn, create, understand, and experience one's potential
What is the 3rd step in the Nursing Process?
What happens in the Planning stage of the nursing process?
A plan developed with the patient to prevent, correct, or relieve health needs. Recognize the patient as the source of control and full partner in providing care based on respect for preferences, values, and needs.
Patient goals must follow SMART. What is that?
Nursing interventions much be specifically designed to & supported?
Meet goal and supported by evidence based practice or scientific rational.
Nursing Interventions are?
Instructions for performing individualized nursing care interventions.
Clear Interventions =?
Successful Client outcomes
Evidence based nursing =?
Nursing prescriptions are?
Orders by the nurse based on the doctor's orders.
Nurses can never prescribe?
Anything you can eat. Ex: medications.
4th step in the nursing process?
What is implementation, 4 things?
- 1. Initiation of care plan.
- 2. Performing Interventions.
- 3. Assessing effectiveness
- 4. Documentation.
Assessing effectiveness requires?
Assess, intervention, and reassess.
5th step of the nursing process?
What is evaluation of the nursing process?
Measuring the degree to which goals/outcomes have been achieved. Identifying factors that positively or negatively influence goal achievement.
Legal documenting is?
Admissible in the court of law. Make sure everything you chart is accurate for YOUR time with the patient only.
What is SBAR?
What does Situation mean in SBAR?
Stating the problem. Ex: "The patient has chest pain."
What does Background mean in SBAR?
Giving a quick history of the patient. Ex: "Patient has a history of chest pain".
What does Assessment mean in SBAR?
Information that is important to relay. Facts. Ex: BP is....
What does Recommendation mean in SBAR?
A request of what you need done to fix the problem. Ex: Nitro ordered for the chest pain.
In what situation would you use SBAR?
When talking to the doctor or other people needing to understand what is going on with your patient.
In nursing notes, nurses should or shouldn't?
Don't use generalizations- good, poor, abnormal, ect.
Avoid judgmental words.
Describe behaviors you see.
Direct quotes from clients as needed.
When should you write incident reports (5)?
- 1. Equipment failure
- 2. Staff Injury
- 3. Client Injury
- 4. Visitor Injury
- 5. Medication Errors