Module 1: Nursing process & Abbreviations Flashcards
What is the definition of the nursing process?
Common framework for developing clinical practice decisions in nursing and a systematic way to problem solving and manage patient care.
What is involved in each of the steps of the nursing process - Assessment
Data Collection:
- Collect subjective and objective information about the patient.
- Collect and document all of the data that you will need to:
- Predict, detect, prevent & manage actual & potential health problems
- Promote optimal health, independence & well-being
- Clarify expected outcomes
Define Subjective data
Subjectively perceived by the person / patient
*maybe confirmed by objective data findings.
> Sample (mnemonic) S: symptoms A: allergies M: medications P: past medical, surgical, family history L: last meal E: events leading up to presentation
Define objective data
Objectively perceived by the person assessing.
> Observations:
- patient as a whole
- signs / manifestations
- body systems assessment (incl. vitals)
- functional health problems / ADLs
> Pathology results
> Imaging results
What are the 7 Body systems used in patient documentation and provide 4 examples of each.
1) CNS : conscious state, pain score, pupil reaction, Glasgow coma scale.
2) CVS: temperature, BP, pulse rate & rhythm, perfusion (colour, warmth & capillary refill)
3) Respiratory: rate & depth, SaO2, breath sounds, O2 delivery route (devices / room air)
4) GIT: diets & fluids, appetite, BSLs, bowel functions
5) Renal: urinary output, IDC care & measures, bladder scans, urinalysis
6) Musculoskeletal / Integumentary: ambulatory status, pressure area care, wounds / dressings, falls risks / interventions
7) Psycho-social: response to illness, emotional well-being, family dynamics, post-discharge support
List the 12 functional health patterns (ADLs)
- maintaining a safe environment
- breathing
- communicating
- eating & drinking
- eliminating
- personal cleansing & dressing
- mobilising
- controlling body temperature
- working & playing
- expressing sexuality
- sleeping
- dying
What is involved in each of the steps of the nursing process - Nursing diagnosis
- Analyse date from assessments to identify & label patient’s response regarding risk factors, resources and signs & symptoms.
- not a medical diagnosis
- problem identification
- provides a basis for selecting nursing plans to achieve outcomes
- ND statement contains:
- What is the problem?
- What caused the problem?
- What signs and/or symptoms made you decide that there was a problem?
What is involved in each of the steps of the nursing process - Planning
- Priority setting
- Planning interventions
- Planning nursing actions
- Nursing orders
- Planning strategies of care
- Set short-term and long-term goals (outcomes)
How should we prioritise / what theories can be used?
- Priorities may change as patients condition changes.
- Prioritise urgency using evidence-based prioritising
- Primary survey
- DRSABCDE (danger, response, airway, breathing, circulation, disability, exposure)
What does it mean to set SMART goals?
S: specific M: measurable A: attainable R: relevant T: time-bound
What is involved in each of the steps of the nursing process - Implementation
- Application
- Intervention
- Nursing care
- Implementation
- Treatment
- Actions taken / care provided to work towards the plans (expected outcomes)
- Evidence-based interventions
- Nurse or Doctor initiated treatments
- Conducted by the nurse, or delegated/referred healthcare professional
- Document nursing interventions & patient response (evidence for evaluation)
What is involved in each of the steps of the nursing process - Evaluation
- Reassessment
- Audit
- Criteria / indicators used to evaluate patient status to decide if expected outcomes have been met.
- Each intervention is evaluated
- Ongoing evaluation of all nursing care provided
- were the outcomes met?
- how is this evidenced?
- what tools/ documentation supports this evaluation?
- Do outcomes / interventions require modification?
