Flashcards in Critical Thinking And The Nursing Process Deck (3)
What are the components of the Nursing Process and what does each entail?
-types: initial, ongoing, emergency, time-lapsed
-methods: observation, interview, physical exam, records
-SIGNS & SYMPTOMS: OBJECTIVE VS. SUBJECTIVE DATA
-objective: what you observe, measure, vitals, SIGNS, etc.
-subjective: what the client feels, reports, says, their perception, SYMPTOMS
-medical: focuses on the disease process (example: strep throat)
-nursing: focuses on patient problems that result from a disease process that nurses can treat within their scope of practice (example: imbalanced nutrition, acute pain)
-NANDA: north american nursing diagnosis association
-types of diagnosis: actual or risk
-how written (PES):
-Etiology (related to)
-Signs and symptoms (as exhibited by, as, manifest by, as evidenced by)
-client centered goals:
SMART: SPECIFIC, MEASURABLE, ACHIEVABLE, REALISTIC, TIMED (BY WHEN)
What patient does, not the nurse. MUST BE MEASURABLE!
-initial, ongoing, discharge. set priorities relative to danger to patient, select nursing strategies, dev plan of care. Consider client's values, priorities, resources available, medical treatment plan
- doing, delegating, recording
-independent, dependent, collaborative
-prevention (primary), treatment (secondary), rehabilitation (tertiary)
-determination of client's progress towards the goals and effectiveness of nursing care
DOCUMENTATION IS KEY:
planning, communication, legal documentation, research, education, quality assurance, accrediting and licensure, reimbursement
What should all patients receive as a standard of practice to eliminate the need to match to specific nursing diagnosis'?
3.) fall safety
5.) receive pneumonia vaccine