Fundamentals of Nursing- Exam 1

What is the Nursing Process? Critical thinking; Provides the framework in which nurses use their knowledge and skills to express human caring. ADPIE & SOAPIE ADPIE A- Assessment: general overview of patient/ health needs; Collects comprehensive data pertinent to the patient's health and/or situation: Info medical personnel can look at & begins the moment you walk through the door D- Diagnosis/ Patient Problem: nursing diagnosis routed on assessments -> related to med diagnosis w/ patient. Analyze the assessment and make a clinical judgement related to an actual or potential health problem. P- Planning/ Goal Setting : goal must be reasonable; long or short term goal with varying time frame attached. I- Intervention/ Rationales: scientific step; done independently or with team to get patient to goal E- Evaluating: determine if patient has reached goal ; goes along w/ planning (follow thru? fall short? met? not met?) 10 Trends to Watch for in Nursing Edu 1) Changing demographic/ diversity 2) Tech explosion 3) Globalization of economy/ society 4) Era of educated consumer 5)Shift to pop-based care + increased complexity 6) cost/challenge of managed care 7/ Impact of policy/ regulation 8) interdisciplinary edu + collab practice 9) Nursing Shortage 10) Advances in science/ research Common Concepts in Nursing Theories 1) *The person 2) the environment 3) health 4) nursing SOAPIE S- Subjective: what patient tells you O- Objective: verifiable info; vital signs (bp, hr, resp/ O2 sat, temp, pain) or sensory info you gather A- Assessment: acts as diagnosis P- Planning: Plan of care I- Intervention: needs rationale E- Evaluation Attributes of a professional nurse 1)Well defined body of specific/ unique knowledge 2) Strong Service Orientation 3) Recognizing authority by professional group 4) Code of ethics 5) Professional organization that sets standards 6) Ongoing research 7) Autonomy and self regulation Subjective vs. Objective data Subjective- What the patient tells you Objective- what you detect during exam; sensory observation and/or verifiable and factual and measurable. Medical vs. Nursing Diagnosis Medical: identify diseases; statement about a specific disease process using terminology from a well-developed classification system accepted by the medical profession. Defining health problem dealt with by physicians. Ex: Myocardial Infarction Nursing Diagnosis: actual or potential health problem that an independent nursing intervention can prevent or resolve (actual problem is present; possible problem may be present, but more data are needed to confirm or disconfirm the problem; defining characteristics are present as risk factors. Focuses on unhealthy responses; Nursing diagnosis is often subject to change (NANDA) Collaborative vs. Independent Intervention Collaborative: working with other health care providers to determine the best mode/ plan of care. The nurse collaborates with other health care team professionals to go about completing the patient's care plan/ chart. Independent: Independent nursing interventions are sanctioned by professional nurse practice acts. They do not require direction or an order from another health care professional. Know the difference between actual (problem-focused), risk, potential (syndrome), and wellness (health promotion) nursing diagnosis Actual (problem focused) Diagnosis- a clinical judgment concerning an undesirable human response to a health condition/life process that exists in an individual, family, group, or community. This type of nursing diagnosis has four components: label, definition, defining characteristics, and related factor. Risk Diagnosis- a clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to health conditions/life processes. Potential (syndrome) Diagnosis- A syndrome is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. Chronic pain syndrome is an example Wellness (health promotion) Nursing Diagnosis- a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential. These responses are expressed by a readiness to enhance specific health behaviors, and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community. Review prioritizing nursing diagnosis according to assessment data What nursing diagnosis is the most important and is affecting the body the most. Ex: Charles Dean -> Chronic confusion is more important than imbalanced nutrition and elimination bc. it affects those two Know the difference between: initial planning, comprehensive planning, ongoing planning, and discharge planning Initial Planning- planning that addresses each problem listed in the prioritized nursing diagnoses and identifies appropriate patient goals and the related nursing care Comprehensive Planning- three basic stages of planning are critical to comprehensive nursing care: initial, ongoing, and discharge. In other settings such as long-term care, hospice care, or a community clinic, initial and ongoing planning may be the primary types of planning. If a nurse develops a comprehensive care plan on the patient's first day but fails to update the plan, the plan will not be effective or efficient. Failure to update the care plan as needed is a common problem in all health care settings. Ongoing Planning- planning carried out by any nurse who interacts with the patient to keep the plan up to date, to facilitate the resolution of health problems, to manage risk factors, and to promote function Discharge Planning- systematic process of preparing the patient to leave the health care facility and for maintaining continuity of care Review the differences between these types of patient outcomes: psychomotor, affective, cognitive, holistic Psychomotor- gaining new skill through physical movement/ reflex actions. Ex: Affective- emotions/ feelings/ attitude. Ex: Cognitive- knowledge; processing info, constructing understanding, applying knowledge, solving problems, conducting research, etc. Ex: Holistic- all nursing practice that has healing the whole person as its goal. How do you write a patient outcome/goal/plan Short Term vs. Long Term Ex: Charles Dean ST: Mr. Dean will urinate 2-3 times before end of shift LT: Mr. Dean will re-establish regular elimination patterns within next week When an assessment changes it is important to know why we modify interventions When an assessment changes, it may alter the course of action, priority of planning or short term/long term goal for the patient. Different data and findings may require a completely different course of treatment and intervention. Understand documentation guidelines The patient record = only permanent legal document that details the nurse's interactions with the patient. Guidelines to follow to avoid legal issues: 1) Content: enter info in complete, accurate, concise, current, and factual manner following nursing process. Make sure info is unbiased, medically worded, sequential, precautionary. Avoid stereotypes or derogatory terms when charting. 2) Timing: follow facility policy regarding the frequency of documentation and modify changes in the patient's status. Late entries are acceptable if something is forgotten. Use military time Never document interventions before carrying them out. Progress notes/ incidence reports