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what are the nursing process steps
- assessment
- diagnosis
- planning/outcome and identification
- implementation
- evaluation
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a series of steps or acts that lead to accomplishing some goal or purpose
process
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3 characteristics of processes
- purpose
- internal organization
- infinite creativity
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a systemic method for providing care to clients
nursing process
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this purpose is to provide individualized holistic effective cliect care efficiently
the nursing process
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used with all clients in any care setting
nursing process
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first step in the nursing process that includes systematic collection, verification, organization, interpretation and documentation of data
assessment
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purpose of assessment is to
identify clients strength and give nurses information about the abilities, behaviors, and skills the client can use during treatment and recovery
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types of assessments
- comprehensive
- focused
- ongoing
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provides baseline client data including a complete health history and current needs assessment. usually completed upon admission
comprehensive assessment
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limited to potential health care risks, particular needs, or health care concerns. not as detailed and often used in short stays
focused assessment
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includes systematic monitoring of specific problemsand is used when follow up is required
ongoing assessment
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client is considered the _____ source of data. the major provider of information about a client
primary
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source of data that is gathered by family members, other health care providers and medical records
secondary source
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data from the cleints point of view that includes perception, feelings, adn concerns. primary way of collecting data
subjective data
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review of the clients functional heatlth pattern prior to the current contact with the health agency, provides much of the subjective data
health history
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observaable and measurable data that are obtained through both standard assessment techniqes and results of labs and diagnostic testing and physical exams
objective data
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process of putting data together in order to identify areas of the clients problem and strength
data clustering
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a framework providing a systematic way to organize data
assessment model
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initial assessment of all physiological needs followed by assessmnet of higher level needs thorugh this model
maslows hierarchy of needs
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model that organizes data collection according to issue and organ function in various body systems
body system model
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data collected through 11 functional health patterns
11 functional health patterns
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developed on clients ability to perform self care activities
theory of self care
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when data is placed in clusters the must be able to
disinguish between relevent and irrelevent data, identify cause and effect
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second step in nursing process that involves further analysis and synthesis of collected data
diagnosis
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breaking down of the whole into parts that can be examined
analysis
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putting data together in a new way
synthesis
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clinical judgement by the physician that identifies or determines a specific disease, condition, or pathological state
medical diagnosis
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related cause or contributor to the problem
etiology
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3 components of nursing diagnosis
- 1. actual nanda diagnosis
- 2. related to
- 3. and AEB
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nursing diagnosis that idicates that a problem exists and is composed of diagnostic labels and s/s
actual nursing diagnosis
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nursing diagnosis with a potential problem. problems that does not yet exist but risk is present
risk nursing diagnosis
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denotes a clients statement of a desire to attain a higher level of wellness in some area of function
wellness nursing diagnosis
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certain physiologic complications that nurses monitor to detect onset or changes in states. always begins with PC - potential complication
collaborative problems
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3rd step in the nursing process that includes both establishing guidelines for the proposed course of nursing action to resolve the nursing diagnosis and developing the clients plan of care
planning
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involves development of a peliminary plan of care by the nurse who perfomrs th aadmission assessment and gathers the comprehenssive admission data
initial planning
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updates the clients plan of care
ongoing planning
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involves anticipation of and planning for the clients needs after discharge
discharge planning
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3 level pproach to prioritizing clienst problems
- first level priority problem
- Airway
- Breathing
- Signs (vital sign problems)
- second level priority
- Mental status change
- Acute pain
- Acute urinary elimination problems
- Untreated medical problems
- Abnormal lab values
- Risk of infection
- Third level priority
- Other health problems
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an aim, intent, or end
goal
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statement that profiles the desired resolution of the nursing diagnosis over a short period of time
short term goal
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profiles desired resolution over a long period of time
long term goal
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specific statemtn describing the methods to be used to acheive the goal
expected outcome
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an action perfomed by th enurse that helps th eclient achieve the results specified by th egoals and expected outcomes
nursing intervention
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3 categories of nursing intervention
- independent
- interdependent
- dependent
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initiated by the nurse and do not require direction or an order from another healh care professional
independent nursing intervention
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implemented collaboratively by th enurse in conjunction with other health care professionals
interdependent intervention
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require an order from a physician or other healthcare professional
dependent nursing intervention
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written guid eor strategies to implement to help the client acheive optimal health
nursing care plan
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is individualized, standardized and begun on the day of admission and continually updated until discharge.
care plan
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4th step in nursing process. performance of the nursing intervention identified during the planning phase
implementation
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an order written in a clients medical record by a physician or nursing care plan by th enurse especially for that individual client . not used for any other client
specific order
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series of standing orders or procedures that should be followed under certain specific conditions
protocol
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5th step in nursing process . determines weather client goals have been met, partially met, or not met.
evaluation
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what should a nurse do if a goal is partially met or ot met
reassess the situation
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what should a nurse do if the goal is met
decide to stop or continuefor the status to be maintained
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avoid making decisions based on wat type of information
outdated, inaccurate, or incomplete information
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primary reasons for documentation
responsibility and accountability
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establish guidelines to ensure safe practice and to demonstrate accountabilityto society
state nursing practice acts
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how can informed consent be given
orally or in writing
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a competent client ability to make health care decisions based on full disclosure of benefits, risks, and potential consequences of a recommended treatment plan
informed consent
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who is responsible for obtaining the clients informed consent
physician
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who often has the client sign the informed consent
nurse
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written instruction about an individuals health care regarding life sustaining measures
advance directive
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elements of effective documentation
document accuratly, completly, objectively
note date and time
use standard abbreviations
write in ink and use appropriate forms
spell correctly
write legibly
sign each entry
chart on every line
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when should medications be charted
immediatly after administration
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a brief worksheet that is traditionally not apart of client medical record. has basic cleint care info
kardex
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kardex info contains
- name
- age
- marital status
- religion
- medical dx
- nursing dx
- allergies
- medical orders
- activities permitted
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occurance report or variance report documents any ususual occurance or accident in the facility
incident report
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