Foundations of nursing Ch 4, 5, 6, K5, K12

• Prioritizing involves placing problem statements/nursing diagnoses or nursing interventions in order of importance
• High priority- life threatening

  medium priority- problems that threaten health

  low priority- problems with no major affect on the person and can be attended to days later
• Knowledge, clinical reasoning, and clinical judgment will help to prioritize the work load
• Priorities constantly change because patient needs and conditions change frequently
• The nursing process is based on the scientific method
• Nurses use critical thinking skills when applying the scientific method
• nursing process

  • assessment
  • diagnosis
  • planning
  • implementation
  • evaluation
• The nursing process is used to identify patients problems and meet patients needs
• To organize a workload you must:

  • list major tasks
  • flexibility/reorder
  • reprioritize every 2 hours
  • know when to delegate tasks to others
• Skills for critical thinking include

  • effective reading
  • effective writing
  • attentive listening
  • effective communicating
• Critical thinking is influenced by professional standards and codes of ethics
• Calling for another pain medication order when the current drug results in the patient feeling nauseas is problem solving
• 1.) Physiologic needs for basic survival take precedence (airway and circulation)

  2.) safety problems take place second
• The interview is not a social interaction
• communication can be verbal or nonverbal for interviewing
• Three stages of the interview:

  1. The opening (rapport is established)
  2. the body (where questions are asked)
  3. the closing (information is summarized)
• Face sheet: age, sex, marital status, occupation, residence, allergies, next of kin
• PCP orders: admitting diagnosis, date of admission, current diet orders, daily weight, medications, IV fluids
• Nurses notes: status sharing the past 24 hours
• PCP progress notes: findings from past 2 days status of problems
• eMAR: medications received, allergies, frequency of PRN medication
• PCP patient history and physical exam: current complaint, chronic problems, physical abnormality findings
• Surgery operative report: procedure done, organs removed, type of Incision, blood loss, complications
• Pathology report: presence of malignancy or infection
• Diagnostic tests: CBC, UA, blood chemistries, x-ray films, culture and sensitivity
• Nursing admission: reason for hospitalization, cigarettes consumed, alcohol consumed, last bowel movement, special diets
• Fall risk assessment: risk factors to consider safety measures to provide for falling
• Skin assessment: risk factors to consider areas needing inspection and care
• Goal: what is to be achieved by nursing intervention
• Short term goals are achievable within 7-10 days or before a patient is discharged
• Long-term goals may take weeks or months to achieve (rehabilitation)
• Expected outcome is the statement of the patient goal
• Subjective data are pieces of information that only the patient really knows and can be verified or described only by the patient
• Objective data are facts that are obtained using the 5 senses and hands on physical assesment. (Data that is factual and can be verified)
• The nurse should perform a quick head-to-toe assessment of each assigned patient at the beginning of each shift
• A functional assessment is performed on patients being admitted to a long-term care facility
• A concept map can show the areas of need, problem statement, goals and nursing interventions
• Expected outcomes are based on the problem statement
• Procedures not documented are considered not performed
• Care is documented on care flow sheets daily