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NURSING PROCESS
A SYSTEMATIC PROBLEM SOLVING APPROACH TOWARD GIVING INDIVIDUALIZED NURSING CARE
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NURSING PROCESS CHARACTERISTICS
- FRAMEWORK FOR PROVIDING NURSING CARE
- ORDERLY AND SYSTEMATIC
- INTERDEPENDANT
- PROVIDES SPECIFIC CARE
- CLIENT CENTERED FOR CLIENTS STRENGTHS
- APPROPRIATE THROUGHT THE LIFESPAN
- CAN BE USED IN ALL SETTINGS
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6 PHASES OF THE NURSING PROCESS
- ASSESSMENT
- DIAGNOSIS
- OUTCOME IDENTIFICATION
- PLANNING
- EMPLEMENTATION
- EVALUATION
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ASSESSMENT
- THE EVALUATION OR APPRAISAL OF A CLIENTS HEALTH STATE
- THE SYSTEMATIC COLLECTION OF SUBJECTIVE AND OBJECTIVE DATA
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PRIMARY SOURCE
THE CLIENT IS THE PRIMARY SOURCE OF INFORMATION
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SECONDARY SOURCE
FAMILY MEMBERS, SIGNIFIGANT OTHERS, OTHER HEALTHCARE PROFESSIONALS, HEALTH RECORDS AND LITERATURE REVIEW
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DIAGNOSIS
- DIAGNOSING ACTUAL OR POTENTIAL HEALTH PROBLEMS
- IDENTIFYING PROBLEMS
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NANDA
NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION
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OUTCOME IDENTIFICATION
DOCUMENTING MEASURABLE, REALISTIC, CLIENT FOCUSED GOALS
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PLANNING
PREPARING A CLIENT PLAN OF CARE
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IMPLEMENTATION
THE INITIATION OF THE PLAN
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EVALUATION
DECIDING WEATHER OR NOT THE PLAN OF CARE WAS A SUCCESS OR FAILURE
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SYSTEMS THEORY
ONE CONCEPTUAL FOUNDTION ON WHICH NURSING PROCESS IS BUILT, ILLUSTRATES HOW THE STEPS OF THE NURSING PROCESS INTERACT WITH EACH OTHER
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INPUT
- THE INFORMATION THAT ENTERS A SYSTEM
- DATA COLLECTED DURING THE ASSESMENT
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THROUGHPUT
THE PROCESS BY WHICH A SYSTEM TRANSFORMS, CREATES AND ORGANIZES INPUT, RESULTS IN THE REORGANIZATION OF THE INPUT
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OUTPUT
- THE END OF A PRODUCT SYSTEM
- IT IS THE CLIENTS HEALTH STATUS
- WHETHER THE CLIENTS HEALTH HAS BEEN MAINTAINED OR IMPROVED
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PROBLEM SOLVING PROCESS
- TAKES PLACE IN THE CLINICAL SETTING AND INVOLVES CLIENTS WITH MULTIPLE PROBLEMS
- UNFORSEEN FACTORS FREQUENTLY INTERVEEN
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DECISION MAKING PROCESS
- IDENTIFYNG THE PROBLEM
- DETERMINE THE ALTERNATIVES
- SELECTING APPROPRIATE ALTERNATIVE
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TYPES OF ASSESMENT
- INITIAL ASSESMENT
- FOCUSED ASSESSMENT
- TIME LAPSE REASSESSMENT
- EMERGENCY ASSESSMENT
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INITIAL ASSESSMENT
WHEN CLIENT ENTER A HEALTHCARE FACILITY OR IS SEEN FOR THE FIRST TIME
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FOCUSED ASSESSMENT
COLLECTING INFORMATION ABOUT A PROBLEM THAT HAS ALLREADY BEEN IDENTIFIED
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TIME LAPSED REASSESSMENT
FOR EVALUATING CHANGES IN THE CLIENTS HEALTH STATUS
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EMERGENCY ASSESSMENT
IN LIFE THREATENING SITUATIONS WHEN PRESERVING LIFE IS THE TOP PRIOROTY
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ASSESSMENT SKILLS
- OBSERVATION
- VISION
- SMELL
- HEARING
- TOUCH
- INTERVIEWING
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4 INTERVIEW PHASES
- PREPATORY PHASE
- INTRODUCTORY PHASE
- MAINTENANCE PHASE
- CONCLUDING PHASE
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PREPATORY PHASE
- BEFORE YOU MEET CLIENT
- READING CHART
- REPORTS
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INTRODUCTORY PHASE
- ALSO CALLED ORIENTATION PHASE
- WHEN NURSE AND CLIENT MEET
- ASKING QUESTIONS
- GETTING AQUAINTED
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MAINTENANCE PHASE
- WORKING PHASE
- CLIENT AND NURSE WORKING TOWARD ACHIEVING A GOAL
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CONCLUDING PHASE
- TERMINATION PHASE
- TO ENSURE THAT THE TERMINATION WILL BE POSITIVE FOR BOTH
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DATA COLLECTION
THE PROCESS OF COMPILING INFO ABOUT THE CLIENT
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PRIMARY SOURCE
THE CLIENT IS THE PRIMARY SOURCE OF DATA
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SECONDARY SOURCES
PROVIDE DATA THAT SUPLIMENT, CLARIFY AND VALIDATE INFORMATION FROM THE CLIENT
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3 FRAMEWORKS FOR COLLECTION AND RECORDING OF ASSESSMENT DATA
- FUNCTIONAL HEALTH PATTERNS MODEL
- HEAD TO TOE MODEL
- BODY SYSTEMS MODEL
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FUNCTIONAL HEALTH PATTERNS MODEL
- CLIENTS STRENGTHS AND ASETS NOTED
- FOCUSES ON NURSING DIAGNOSIS
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HEAD TO TOE MODEL
SYSTEMATICALLY EXAMINING EVERY PART OF THE BODY FROM THE HEAD TO TOE
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BODY SYSTEMS MODEL
FOCUSES ON MAJOR ANATOMIC SYSTEMS
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NURSING DIAGNOSIS
- USED TO IDENTIFY PROBLEMS AND SYNTHASIZE INFORMATION GATHERED IN THE ASSESSMENT
- DESCRIBES A HEALTH RISK THAT THE NURSE IS RESPONSIBLE FOR TREATING INDEPENDANTLY
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TAXONOMY
CLASSIFICATION SYSTEM
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MEDICAL DIAGNOSIS
- DESCRIBES A DISEASE OR PATHOLOGY OF SPECIFIC BODY SYSTEMS
- FOCUSES ON TREATING THE UNDERLYING PATHOLOGY
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COLLABORATIVE HEALTH PROBLEMS
REQUIRES A NURSE AND A DR.
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DIAGNOSTIC LABEL
THE NAME OF THE NURSING DIAGNOSIS AS LISTED IN THE NANDA TAXONOMY
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DESCRIPTORS
WORDS USED TO GIVE ADDITIONAL MEANING TO A NURSING DIAGNOSIS
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DEFINITION
- NURSING DIAGNOSIS WOULD NOT BE
- HYPOTHERMIA
- YOU WOULD USE
- BODY TEMP BELOW NORMAL RANGE
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CUES
SUBJECTIVE AND OBJECTIVE INFO
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CLUSTERS
FORMED FROM SEVERAL CUES WHICH IS THEN INTERPRETED AND VALIDATED
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ACTUAL NURSING DIAGNOSIS
- THREE PART STATEMENT INCLUDES DIAGNOSTIC LABEL, RELATED FACTORS, DEFINING CHARICTERISTICS
- ACUTE PAIN RELATED TO SURGICAL TRAUMA AND INFLIMATION AS EVIDENCED BY GRIMACING AND VERBAL REPORTS OF PAIN
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RISK NURSING DIAGNOSIS
- TWO PART STATEMENT THAT INCLUDES DIAGNOSTIC LABELS AND RISK FACTORS
- RISK FOR INFECTION RELATED TO SURGERY AND IMMUNOSUPPRESSION
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POSSIBLE NURSING DIAGNOSIS
- TWO PART STATEMENT THAT INCLUDES DIAGNOSTIC LABEL, RISK FACTORS
- POSSIBLE SELF ESTEEM DISTURBANCE RELATED TO UNKNOWN ETIOLOGY
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WELLNESS DIAGNOSIS
- ONE PART STATEMENT THAT INCLUDES DIAGNOSTIC LABEL
- READIENESS FOR ENHANCED SPIRITUAL WELLBEING
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SIGNIFIGANCE OF NURSING DIAGNOSIS
PROVIDES A MEANS OF COMMUNICATING NURSING REQUIREMENTS FOR CLIENT CARE TO OTHER NURSES HEALTHCARE MEMBERS AND THE PUBLIC
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OUTCOME IDENTIFICATION
- FORMULATION OF GOALS AND MEASURABLE OUTCOMES THAT PROVIDE THE BASIS FOR EVALUATING THE NURSING DIAGNOSIS
- ESTABLISHING PRIORITIES
- ESTABLISH CLIENT GOALS AND OUTCOME CRITERIA
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PRIORITY
A CHOICE THAT COMES FIRST FROM OTHER POSSIBLE OPTIONS
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CLIENT OUTCOME
WHAT THE CLIENTS STATE WILL BE AFTER INTERVENTIONS ARE EFFECTED
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PLANNING
- PLAN OF CARE
- PLAN NURSING INTERVENTIONS
- PROMOTES CONTINUITY OF CARE
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CORRECT PLAN OF CARE DOCUMENTATION
- AMBULATES 30 FT IN HALL BEFORE DISCHARGE
- CLIENT WALKS IN HALL
- SMALL SHIFTS IN BODY WEIGHT TO PROMOTE CIRCULATION AND PREVENT SKIN BREAKDOWN
- CHANGE POSITION EVERY 2 HOURS
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3 PO DRUG PHASES
- PHARMACEUTIC PHASE
- PHARMACOKINETIC PHASE
- PHARMACODYNAMIC PHASE
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PHARMACEUTIC PHASE
- IST PHASE OF DRUG ACTION
- TABLET GOES THROUGH DISINTIGRATION AND DISSOLUTION
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PHARMACOKINETIC PHASE
- 2ND PHASE
- THE PROCESS OF DRUG MOVEMENT TO ACHIEVE AN ACTION
- ABSORBTION DISTRIBUTION METABOLISM AND EXCRETION
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ABSORBTION
MOVEMENT OF DRUG FROM THE GI TRACT TO THE BODY FLUIDS
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DISTRIBUTION
THE DRUG BECOMES AVAILABLR TO THE BODY FLUIDS AND TISSUES
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METABOLISM
- LIVER IS THE PRIMAR SITE
- ALSO GI TRACT
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EXCRETION
KIDNEYS ARE THE PRIMARY SITE
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PHARMACODYNAMIC PHASE
THE STUDY OF DRUG CONCENTRATION AND ITS EFFECTS ON THE BODY
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THERAPUTIC RANGE
- ESTIMATES THE MARGIN OF SAFETY
- THE CLOSER TO 1 THE GREATER THE DANGER OF TOXICITY
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LOW THERAPUTIC RANGE
HAVE A NARROW MARGIN OF SAFETY
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HIGH THERAPUTIC RANGE
WIDE MARGIN OF SAFETY
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PEAK AND TROUGH
WHEN THE BLOOD PLASMA CONCENTRATION OF A DRUG IS AT ITS HIGHEST AND LOWEST LEVELS
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LOADING DOSE
- IMMEDIATE DRUG RESPONSE IS DESIRED
- A LARGER INITIAL DOSE IS REQUIRED TO GET THE PATIENT INTO THE THERAPUTIC RANGE
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1970 THE CONTROLED SUBSTANCE ACT
- DESIGNED TO SOLVE DRUG ABUSE
- PROMOTION OF DRUG EDUCATION AND RESEARCH INTO THE PREVENTION AND TREATMENT OF DRUG DEPENDANCE
- STRENGTHENING OF ENFORCEMENT AUTHORITY
- ESTABLISHED REHAB FACILITIES
- DESIGNATION OF SCHEDULES OF DRUGS
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SCHEDULE 1
- DRUGS WITH HIGH ABUSE POTENTIAL
- NO MEDICAL USE
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SCHEDULE 2
- HIGH POTENTIAL FOR ABUSE
- HAS A MEDICAL USE
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SCHEDULE 3
- MEDICALLY ACCEPTED DRUGS
- POTENTIAL FOR ABUSE IS LOWER
- MAY CAUSE DEPENDANCE
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SCHEDULE 4
- MEDICALLY ACCEPTED DRUG
- MAY CAUSE DEPENDANCE
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SCHEDULE 5
- MEDICALLY ACCEPTED
- LOW POTENTIAL OF DEPENDANCE
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