Karteikarten
Lecture 9 Nursing Process
Karten in diesem Stapel (40)
- 1nursing processsystematic and rational method for planning, providing individula nursing
--> overlapping
--> implementation, evalutating have assessment as well - 2purpose of nursing process- identify client health status
--> potential and actual care
- estabolism plan to meet client need
- specific nursing intervention - 3characteristic of nursing process- cyclic, dynamic not static
- client center
- problem sloving and critical thinking skill
- clinical reasoning and decision making skill
- interperosnal and collaborative
- universal applicability - 4type of assessmentinital nursing assessment
problem-focused assessment
emergency assessment
time-lapsed reassessment - 5collect datasympathetic, continuous
past history, current problem - 6type of data1. subjective data
--> covert data
--> apparent only to person affect
Eg. sensation, feeling, value
2. objective data
--> overt data
-->detectable by an observer
--> show be measured by standard
--> seen, felt, smelled
=> by observation, physical examination - 7source of data1. primary source
--> data provide by client
--> best for the patients who are ill, young, confused
2. secondary source
--> family member, health professional
record, response - 8data collection method1. observation
2. interview
3. physical examination - 9observationgathering data using sense
Eg. skin color, body and breath - 10interviewAim: get and give information
identfy problem of mututal concern
evalute change
provide educaiotn
--> plan communication, planning interview
--> open-ended, closed ended question - 11physicla examinationsystemic data- collection method
method: cephalocaudal approach
--> head to toe
screening examination - 12data of physical examinationobservation and inspection
auscultation
palpation and percussion
measurement of vital sign, height and weight - 13organized data1. nursing conceptual and framework
--> gordon's functional health pattern
--> orem's self care model
-->roy's adaption model
2. wellness model
--> assist client to idenify and expolre lifesystle and habit
3. non nursing model
--> body system theory
--> malslow's hieraracy of need
4. developmental theory
oral (0-18 month)
anal (18-3.5)
phallic (3.5-6)
latency (6-puberty)
genital (puberty-adulthood) - 14validate datadouble check
ensure the assessment of informaiton complete
objective agree to subject
avoid jumping to conclusion
overlooked - 15cue and influcne of validate datacue
--> subjective, objective directly observe from patient
influence
--> based on cue - 16document datarecord data (factual)
without stating interperstating
--> record subjective with quote - 17diagnosingclinical judgement about client response to acute and potential
reflect to patient present suitation
change over time
differ from medical diagnosis - 18background of dianosingNANDA (north american nursing diagnosis association)
-> 1982
--> define, refine, promote a taxonoy of nursing
--> 235 - 19type of diagnosis1. actual diagnosis
2. health diagnosis
3. risk nursing diagnosis
4. symptom diagnosis - 20actual diagnosisproblem present at the time
assoicate with sign and symptom
Eg. urinary infectioin - 21health promotionpreparation to implement behavoir to improve condition
- 22risk nursing diagnosisX existing
have the risk faction
Eg. risk of infection - 23symptom diagnosisclutter have similiar intervention
- 24diagnosis statement1 problem (dianogitic label)
--> related to
2. etiology (contributing factor)
--> as evidence by
3. symptom
(sign and symptom) - 25planning- setting prioritiesnurse - establishing a preferential sequence
high proiority level (life-threatening)
medium proiority level (health- threatening)
low proiority (developmental need) - 26factor to considerclient health value, belief
clinet pripority
resource available to nurse and client
urgency of health problem
medical diagnosis treatment - 27planning- establishing client goal/ desired outcome -purposeprovide direction for planning intervention
-serve as criteria for evaluting progress
-enable the client and nurse to determine when the problem reslove
-help motivate the client and nuse
(a sense of achievement) - 28goalbroad statement about the client status
--> short, long term
short
--> long term is not difficult
--> a sense of satisfaction - 29desired, expected outcomemore specific, observable critieri, used to evalute the goal
--> subject, verb, condition and modifiers, criterion of desired performance - 30guideline for writing goalrealtic
in term of client response
ensure compatitbility with therapy of other professional
use observable and measurable term - 31selective nursing intervention- type1. independent intervention
--> activites that nurse licensed to do
2. dependent intervention
--> activites carry out under primary nurse, led by supervisor, according to specifc routine
3. collaborative intervention
--> action carry out by collaborative team with health care professional - 32criteriasafe and approciate
resource available
based on client value, belief, culture
match to therapies
based on experience
standard of case - 33writing nursing interventiondate
verb
condition
time element
assist the client with tub bat at 0700 daily - 34implemention - skill1. cognitive skill
--> problem sloving
2. interpersonal skill
--> verbal
3. technical skill
--> clinical skill - 35reassess clientreassess that the intervention still need
- 36determing the need of assistancethe task can not be perform safely
decrease client stress
lack of knowledge to implement - 37supervising delegated caremonitor the progess of delegated care
validate and response any adverse side effect - 38documenting nursing activitesdocument and nursing intervetion and client response
--> do not record in advance - 39evalutationcollect data
compared data with desired goal
related nurse activites to outcome
drawing conclusion
continuing, modifying, terminating the care plan - 40exampleactual problem have been resolved the potential problem is no longer existing
X
--> more time
--> care plan need to revised
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- Fundamental Concepts of Health and Nursing (Lecture 9 Nursing Process) Karteikarten am Lecture 9 Nursing Process, erstellt von katy` kim am 28/11/2017.
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