nursing test 2

A SYSTEMATIC PROBLEM SOLVING APPROACH TOWARD GIVING INDIVIDUALIZED NURSING CARE

• 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

• ASSESSMENT
• DIAGNOSIS
• OUTCOME IDENTIFICATION
• PLANNING
• EMPLEMENTATION
• EVALUATION

• THE EVALUATION OR APPRAISAL OF A CLIENTS HEALTH STATE
• THE SYSTEMATIC COLLECTION OF SUBJECTIVE AND OBJECTIVE DATA

THE CLIENT IS THE PRIMARY SOURCE OF INFORMATION

FAMILY MEMBERS, SIGNIFIGANT OTHERS, OTHER HEALTHCARE PROFESSIONALS, HEALTH RECORDS AND LITERATURE REVIEW

• DIAGNOSING ACTUAL OR POTENTIAL HEALTH PROBLEMS
• IDENTIFYING PROBLEMS

NORTH AMERICAN NURSING DIAGNOSIS ASSOCIATION

DOCUMENTING MEASURABLE, REALISTIC, CLIENT FOCUSED GOALS

PREPARING A CLIENT PLAN OF CARE

THE INITIATION OF THE PLAN

DECIDING WEATHER OR NOT THE PLAN OF CARE WAS A SUCCESS OR FAILURE

ONE CONCEPTUAL FOUNDTION ON WHICH NURSING PROCESS IS BUILT, ILLUSTRATES HOW THE STEPS OF THE NURSING PROCESS INTERACT WITH EACH OTHER

• THE INFORMATION THAT ENTERS A SYSTEM
• DATA COLLECTED DURING THE ASSESMENT

THE PROCESS BY WHICH A SYSTEM TRANSFORMS, CREATES AND ORGANIZES INPUT, RESULTS IN THE REORGANIZATION OF THE INPUT

• THE END OF A PRODUCT SYSTEM
• IT IS THE CLIENTS HEALTH STATUS
• WHETHER THE CLIENTS HEALTH HAS BEEN MAINTAINED OR IMPROVED

• TAKES PLACE IN THE CLINICAL SETTING AND INVOLVES CLIENTS WITH MULTIPLE PROBLEMS
• UNFORSEEN FACTORS FREQUENTLY INTERVEEN

• IDENTIFYNG THE PROBLEM
• DETERMINE THE ALTERNATIVES
• SELECTING APPROPRIATE ALTERNATIVE

• INITIAL ASSESMENT
• FOCUSED ASSESSMENT
• TIME LAPSE REASSESSMENT
• EMERGENCY ASSESSMENT

WHEN CLIENT ENTER A HEALTHCARE FACILITY OR IS SEEN FOR THE FIRST TIME

COLLECTING INFORMATION ABOUT A PROBLEM THAT HAS ALLREADY BEEN IDENTIFIED

FOR EVALUATING CHANGES IN THE CLIENTS HEALTH STATUS

IN LIFE THREATENING SITUATIONS WHEN PRESERVING LIFE IS THE TOP PRIOROTY

• OBSERVATION
• VISION
• SMELL
• HEARING
• TOUCH
• INTERVIEWING

• PREPATORY PHASE
• INTRODUCTORY PHASE
• MAINTENANCE PHASE
• CONCLUDING PHASE

• BEFORE YOU MEET CLIENT
• READING CHART
• REPORTS

• ALSO CALLED ORIENTATION PHASE
• WHEN NURSE AND CLIENT MEET
• ASKING QUESTIONS
• GETTING AQUAINTED

• WORKING PHASE
• CLIENT AND NURSE WORKING TOWARD ACHIEVING A GOAL

• TERMINATION PHASE
• TO ENSURE THAT THE TERMINATION WILL BE POSITIVE FOR BOTH

THE PROCESS OF COMPILING INFO ABOUT THE CLIENT

THE CLIENT IS THE PRIMARY SOURCE OF DATA

PROVIDE DATA THAT SUPLIMENT, CLARIFY AND VALIDATE INFORMATION FROM THE CLIENT

• FUNCTIONAL HEALTH PATTERNS MODEL
• HEAD TO TOE MODEL
• BODY SYSTEMS MODEL

• CLIENTS STRENGTHS AND ASETS NOTED
• FOCUSES ON NURSING DIAGNOSIS

SYSTEMATICALLY EXAMINING EVERY PART OF THE BODY FROM THE HEAD TO TOE

FOCUSES ON MAJOR ANATOMIC SYSTEMS

• USED TO IDENTIFY PROBLEMS AND SYNTHASIZE INFORMATION GATHERED IN THE ASSESSMENT
• DESCRIBES A HEALTH RISK THAT THE NURSE IS RESPONSIBLE FOR TREATING INDEPENDANTLY

CLASSIFICATION SYSTEM

• DESCRIBES A DISEASE OR PATHOLOGY OF SPECIFIC BODY SYSTEMS
• FOCUSES ON TREATING THE UNDERLYING PATHOLOGY

REQUIRES A NURSE AND A DR.

THE NAME OF THE NURSING DIAGNOSIS AS LISTED IN THE NANDA TAXONOMY

WORDS USED TO GIVE ADDITIONAL MEANING TO A NURSING DIAGNOSIS

• NURSING DIAGNOSIS WOULD NOT BE
• HYPOTHERMIA
• YOU WOULD USE
• BODY TEMP BELOW NORMAL RANGE

SUBJECTIVE AND OBJECTIVE INFO

FORMED FROM SEVERAL CUES WHICH IS THEN INTERPRETED AND VALIDATED

• 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

• TWO PART STATEMENT THAT INCLUDES DIAGNOSTIC LABELS AND RISK FACTORS
• RISK FOR INFECTION RELATED TO SURGERY AND IMMUNOSUPPRESSION

• TWO PART STATEMENT THAT INCLUDES DIAGNOSTIC LABEL, RISK FACTORS
• POSSIBLE SELF ESTEEM DISTURBANCE RELATED TO UNKNOWN ETIOLOGY

• ONE PART STATEMENT THAT INCLUDES DIAGNOSTIC LABEL
• READIENESS FOR ENHANCED SPIRITUAL WELLBEING

PROVIDES A MEANS OF COMMUNICATING NURSING REQUIREMENTS FOR CLIENT CARE TO OTHER NURSES HEALTHCARE MEMBERS AND THE PUBLIC

• FORMULATION OF GOALS AND MEASURABLE OUTCOMES THAT PROVIDE THE BASIS FOR EVALUATING THE NURSING DIAGNOSIS
• ESTABLISHING PRIORITIES
• ESTABLISH CLIENT GOALS AND OUTCOME CRITERIA

A CHOICE THAT COMES FIRST FROM OTHER POSSIBLE OPTIONS

WHAT THE CLIENTS STATE WILL BE AFTER INTERVENTIONS ARE EFFECTED

• PLAN OF CARE
• PLAN NURSING INTERVENTIONS
• PROMOTES CONTINUITY OF CARE

• 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

• PHARMACEUTIC PHASE
• PHARMACOKINETIC PHASE
• PHARMACODYNAMIC PHASE

• IST PHASE OF DRUG ACTION
• TABLET GOES THROUGH DISINTIGRATION AND DISSOLUTION

• 2ND PHASE
• THE PROCESS OF DRUG MOVEMENT TO ACHIEVE AN ACTION
• ABSORBTION DISTRIBUTION METABOLISM AND EXCRETION

MOVEMENT OF DRUG FROM THE GI TRACT TO THE BODY FLUIDS

THE DRUG BECOMES AVAILABLR TO THE BODY FLUIDS AND TISSUES

• LIVER IS THE PRIMAR SITE
• ALSO GI TRACT

KIDNEYS ARE THE PRIMARY SITE

THE STUDY OF DRUG CONCENTRATION AND ITS EFFECTS ON THE BODY

• ESTIMATES THE MARGIN OF SAFETY
• THE CLOSER TO 1 THE GREATER THE DANGER OF TOXICITY

HAVE A NARROW MARGIN OF SAFETY

WIDE MARGIN OF SAFETY

WHEN THE BLOOD PLASMA CONCENTRATION OF A DRUG IS AT ITS HIGHEST AND LOWEST LEVELS

• IMMEDIATE DRUG RESPONSE IS DESIRED
• A LARGER INITIAL DOSE IS REQUIRED TO GET THE PATIENT INTO THE THERAPUTIC RANGE

• 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

• DRUGS WITH HIGH ABUSE POTENTIAL
• NO MEDICAL USE

• HIGH POTENTIAL FOR ABUSE
• HAS A MEDICAL USE

• MEDICALLY ACCEPTED DRUGS
• POTENTIAL FOR ABUSE IS LOWER
• MAY CAUSE DEPENDANCE

• MEDICALLY ACCEPTED DRUG
• MAY CAUSE DEPENDANCE

• MEDICALLY ACCEPTED
• LOW POTENTIAL OF DEPENDANCE