NCM MIDTERM

• Nursing process

  Systematic, rational method of planning and providing individualized nursing care

  
• Nursing process


  • Identify client's health status and actual or potential health care problems or needs
  • Establish plans to meet needs
  • Deliver specific interventions

  
• Phases of the nursing process

  • Assessing (Assessment)
  • Diagnosing (Nursing Diagnosis)
  • Planning
  • Implementing
  • Evaluating

  
• Sometimes included in the nursing process: Identifying outcomes, in between diagnosing and planning (Outcome Criteria)

  
• Nursing process


  • Cyclic and dynamic rather than static
  • Client centered
  • Problem-solving and systems theory
  • Decision making
  • Interpersonal and collaborative
  • Universal applicability
  • Critical thinking skills
  • Clinical reasoning skills

  
• Assessing


  Systematic and continuous collection, organization, validation, and documentation of data (information)
• Types of assessment


  • Initial nursing assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment

  
• Initial nursing assessment for each client includes history and physical examination, performed and documented within 24 hours of admission

  
• Subjective data


  Symptoms or covert data, apparent only to person affected, can be described only by person affected, includes sensations, feelings, values, beliefs, attitudes, and perception of personal health status and life situations
• Objective data


  Signs or overt data, detectable by an observer, can be measured or tested against an accepted standard, can be seen, heard, felt, or smelled, obtained through observation or physical examination
• Subjective data


  • "Isang araw na ako suka nang suka."
  • Body malaise
• Objective data

  • BP 160/100mmHg
  • Diarrhea
  • Pain
  • Elevated CBG level
  • Yellowish fluid that oozes from the wound
  • Full-minute RR and PR
  • O2 saturation level at 100%
• Sources of data


  • Client, best source unless too ill, young, or confused to communicate clearly
  • Family members, significant others, secondary source if client cannot speak for him- or herself
  • Support people, family members, friends, caregivers, person giving information may wish to remain anonymous, secondary subjective data
  • Client records, medical records, records of therapies, laboratory records, to avoid repeated questioning and concerns about lack of communication among health professionals
  • Health care professionals, important to ensure continuity of care when clients transferred to and from home and health care agencies
  • Literature, standards or norms against which to compare findings, current methodologies and research findings, secondary objective data
• Data collection methods


  • Observing, gathering data using the senses
  • Interviewing, planned communication or a conversation with a purpose, focused interview
• Data collection methods


  • Observing
  • Gathering data using the senses
  • Interviewing
  • Examining
• Observing


  Used to obtain data on skin color, body or breath odors, lung or heart sounds, skin temperature
• Interviewing


  Planned communication or a conversation with a purpose
• Focused interview


  Nurse asks the client specific questions to collect information related to the client's problem
• Interviewing


  • Used to get or give information
  • Identify problems of mutual concern
  • Evaluate change
  • Teach
  • Provide support
  • Provide counseling or therapy
• Directive interview


  Nurse establishes purpose and controls the interview, used to gather and give information when time is limited
• Nondirective interview


  Client controls the purpose, subject matter, and pacing, rapport is important
• Types of interview questions

  • Closed questions
  • Open-ended questions
  • Neutral questions
  • Leading questions
• Planning the interview and setting

  • Time (client free of pain, limited interruptions)
  • Place (private, comfortable environment, limited distractions)
  • Seating arrangement
  • Language (use easily understood terms, interpreter or translator)
• Stages of an interview

  1. The opening (establish rapport, orient client)

  2. The body (client communicates, nurse asks questions)

  3. The closing (nurse ends interview when necessary information is collected)
• Examining


  • Systematic data-collection method using observation and inspection, auscultation, palpation, and percussion
  • Vital signs, height and weight
  • Cephalocaudal approach
  • Screening examination
• Conceptual models/frameworks


  • Gordon's functional health pattern framework
  • Orem's self-care model
  • Roy's adaptation model
• Wellness models


  • Assist clients to identify and explore lifestyle habits and health behaviors, beliefs, values, and attitudes
• Non-nursing models

  • Body systems model
  • Maslow's Hierarchy of Needs
  • Developmental theories (Havighurst, Freud, Erikson, Piaget, Kohlberg)
• Validation


  The act of "double-checking," verifying data to confirm it is accurate and factual
• Cues


  Subjective, objective data that can be directly observed by the nurse
• Inferences


  Nurse's interpretation based on cues
• Record client data in a factual manner without stating interpretations, record subjective data with quotes in client's own words
• Nursing diagnosis


  A statement of nursing judgment based on education, experience, expertise and license to treat, describing human response, the client's physical, sociocultural, psychological, and spiritual responses to an illness or health problem

  
• Medical diagnosis


  Made by a physician, refers to a disease process, remains the same as long as the disease process is present
• Differences between nursing diagnosis and medical diagnosis

  • Nursing diagnosis changes when client's responses change, independent nursing functions
  • Medical diagnosis refers to a disease process, remains the same, dependent nursing functions (physician-prescribed therapies and treatments)
• Nursing diagnosis


  • Includes only those health states that nurses are educated and licensed to treat
  • Judgment made only after thorough, systematic data collection
  • Continuum of health states
• Status of nursing diagnoses

  • Actual diagnosis
  • Health promotion diagnosis
  • Risk nursing diagnosis
  • Syndrome diagnosis
• Actual diagnosis


  Problem presents at the time of assessment, presence of associated signs and symptoms
• Health promotion diagnosis


  Preparedness to implement behaviors to improve their health condition
• Risk nursing diagnosis


  Problem does not exist, presence of risk factors