Biographical Data
provides pertinent information about facts or events in a person's life
Cue
subjective or objective data
Defining Characteristiics
signs/ symptoms that furnish evidence that the problem exists
Outcome
a statement that describes a specific measureable behavior
Problem
any health care condition that requires intervention
Risk Nursing Diagnosis
a clinical judgment that a problem may develop
Wellness Nursing Diagnosis
readiness for enhanced nutrition
6 phases of the Nursing Process
assessment, diagnosis, outcome identification, planning, implementation, evaluation
Nursing Process
provides a framework for the practice of nursing
Assessment Phase
the patient's information and data are collected
Diagnosis
the nurse identify the health problems
Planning phase
nurse sets priorities for nursing intervention
Implementation
nurse instructs the patient on the use of her inhaler
Sources that are used to obtain information for the patient database
primary and secondary
Primary
the patient
Secondary
family, significant others, medical records
Objective
observable and measureable signs
Subjective
symptoms, secret until shared
Data Clustering
the grouping of related cues
Four Components of a Nursing Diagnosis
nursing diagnosis title/ label, definition of the title/ label, contributing/ etiologic/ related factors, defining characteristics
Four types of nursing diagnosis statements
actual, risk, syndrome and wellness
Nursing Diagnosis
a clinical judgment about individual, group or community responses to actual or potential health problems
Risk Diagnosis
actual factors are present in a circumstances
Maslow's Hierarchy of Needs
phsiologic needs, safety and security, love and belonging, self-esteem, self-actualization
Patient-centered outcomes
specific to the patient and the patient's problems
Included in a nursing order
date, signature of nurse responsible for the care plan, subject, action verb, qualifying details
Nursing order is created because
specific written instructions for all caregivers
Steps in teh evaluation of the nursing care plan
nurse review the pateint-centered goals, reassesses the patient to gather data indicating the patient's actual response to the nursing interventions, compares teh actual otucome with the desired outcome
General Activities of NANDA, NIC, and NOC
standarized languages
Patient-centered outcomes should be statements that are
specific to the patient and teh patient's problems
Possible nursing actions that may be implemented
performing an activity for a patient, assisting the patient to perform an activity, teaching the patient or family about health maintenance
Case Management
assignment of a health care provider to an individual patient
Clinical Pathway
a multidisciplinary plan for clinical interventions
Variance
when an expected outcome is not reached
The Nursing Process
a problem-solving method, systematic, goal-directed, flexible, rational approach, ensures consistent, continuous, quality nursing care, provides a basis for professional accountability, input of nurse and patient/ family critical
The steps of the nursing process
assessment, diagnosis, plan (outcomes, interventions), implement, evaluate
Assessment
the first phase in the nursing process is teh systematic gathering of relevant and important patient data, teh data are information or facts about the patinet, comprehensive, focused, ongoing, answers the questions (actual problem) what could happen (pote
Nursing Diagnosis
diagnosis is the reasoning process used to interpret data in order to draw conclusions, and to make a nursing diagnosis, which is a conclusion about the patient's health status, a statement that describes a specific human response to an actual or potentia
Outcome Identification
to provid consistent, continuous care that will meet the patient's unique needs which includes patient outcomes and interventions, what will the patient do to resolve or lessen the problem identified int the nursing diagnosis? By when will this be accompl
Patient Outcomes or Goals
describe the desired result of nursing care
Patient Outomes
are directly related to the patients's problem as stated in the nursing diagnosis
Plan Interventions
choose the interventions that are most likely to bring about the desired changes
Implementation
the phase in which the nurse performs or delegates teh activities necessary for achieving the clinet's health goals
Implement
carry out the care plan, can include delegation of tasks to staff, reassess the patient, validate that the are plan is accurate, carry out nurses' orders and medical orders such as medications, irrigations and oxygen therapy, document on patients chart, t
Evaluate
compare the patient's current status with the stated patient outcomes, evaluation is teh process of judging the effetiveness of what has been done, were the outcomes achieved? why not? where they partially met?, date when the outome was met and initial or
Role of the Practical Nurse in the Nursing Process
assessing, observe and report significant cues to the nurse in charge or to the physician, diagnosisng, assist with the determination of acurate nursing diagnoses and gather further data to confirm or eliminate problems, expected outcomes/planning, assist
Critical Thinking
is reflective and reasonable thinking that is focused on deciding what to believe or do, its the art of thinking about your thinking while you are thinking so as to make your thinking more clear, precise, acurate, relevant, consistent and fair, reason, re
What critical thinking is NOT
common sense, spontaneous responses, regular, normal thinking, being critial or judgmental, disorganized, task-oriented, working in isolation, being competitive, inability to ommunicate with others, emotion-driven
THINK
total recall, habits, inquiry, new ideas and creativity, knowing how you think
Total Recall
memory
Habits
repeated thinking approaches
Inquiry
examining issues
Knowing how you think
reflection
Seven habits of highly effective people
be proactive, begin with the end in mind, put first things first, think win-win, seek first to understand, then to be understood, synergize, sharpen the saw
Characteristis of Critical Thinking
it's rational and reasonable, it involves conceptualization, it requires reflection, in involves both cognitive (thinking) skills and attitudes (feelings), it involves creativity, it requires knowledge
Critical Thinking attitudes
independent, intellectual humility, intellectual courage, intellectual integrit, intelletual perseverance, intellectual curiosity, faith in reason, fiar-mindedness, interest in exploring thoughts and feelings
Critical Thinking Skills
using language precisely, recognizing differences in perception, distinguishing facts from interpretations, questioning to clarify, compare and contrast ideas and practice, judge and evaluate, reasoning; recongize assumptions
Obstacles to Critical Thinking
habits and ruts, anxiety
Anxiety
be sure you are well prepared for clinical, make certain that your instrcutors ask about your rationale, consciously slow down your breathing, allow yourself to think aloud, remind yourself that you are a learner
Cluster Group Data
malsow's hierarchy of needs, gordon's functional health patterns