NUR 2115final concept guide

Review various nursing diagnoses related to specific patient problems · Oxygenation · Ineffective Airway Clearance: fatigue, COPD. Thick, yellow secretions · Impaired Gas Exchange: smokers, asbestos workers. Cyanosis altered blood gases · Ineffective Breathing Pattern: anxiety. Hyperventilating, tachypneic. · Infection · Risk for Infection: chronic illness (diabetes), alteration in skin integrity. S/S of infectious process, drainage or secretions. · Thermoregulation · Ineffective Thermoregulation: Trauma, illness environmental temp. Fluctuations in body temp above or below normal. Hyperthermia and Hypothermia. · Tissue Integrity · Impaired Tissue Integrity and Risk for Impaired Tissue Integrity: Alteration in metabolism, extremes of age. Damaged or destroyed tissue. Module 1-3 Concepts: • P- Population/Problem • I- Intervention(s) • C-Comparison (optional) • O-Outcome • “What interventions reduce the incidence and severity of bed sores in residents of long-term care facilities?” • P- Elderly • I- Bedsores or pressure ulcers • C- None • O- Reduction in incidence and severity of bed sores • International Council of Nurses- Promotion of health, prevention of illness, and the care of ill, disabled, and dying people • American Nurse Association-Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, groups, communities, and populations.• Main concepts central to nursing: person, health, environment, nursing • Patient is “central focus” of all definitions – Includes physical, emotional, social, and spiritual dimensions of the patient • Review importance of documentation of patient assessments Identify actual and potential health problems Make nursing diagnoses Plan appropriate care Evaluate patient’s responses to treatment Formats for Nursing Documentation o Initial nursing assessment: obtained from nursing history and physical assessment o Care plan: patient’s dx, related goals, outcomes, interventions, resolutions to problems o Patient care summary: overview of valuable patient information such as documentation, lab and test results, orders, medications o Critical collaborative pathways: standardized plan of care developed for a specific patient population with a designated dx (can include list of interventions) o Progress notes: pt’s progress towards achieving expected outcomes… description of the status of the problem, related nursing interventions, pt responses, and needed revisions to the POC. o Communication: primary purpose of patient record!! Helps health care professionals from different disciplines (who interact with patient at different times) communicate with one another o Diagnostic and therapeutic orders: The chart contains any diagnoses, new and old, and MD orders and results of diagnostic tests o Care planning: Modify care plan based on patient’s baseline and ongoing data o Quality process and performance improvement: Accrediting agencies, such as TJC, can review patient records to determine if the hospital or facility is meeting it’s standards. They can review nurse’s charting to ensure patients are receiving quality and competent care o Research; decision analysis: Uses patient record to identify needs to promote EBP o Education: Students and health care professionals will learn from patient’s chart o Credentialing, regulation, and legislation: reviewers can monitor health care compliance within the facility o Reimbursement: Insurance (payers) need to use patient records to reimburse for health care received