funda finals

• Nurses apply the nursing process as a competency when delivering patient care
• Critical thinking


  Necessary in the application of the five-step nursing process: assessment, diagnosis, planning, implementation, and evaluation
• Purpose of the nursing process

  To diagnose and treat human responses (example: patient symptoms, need for knowledge) to actual or potential health problems
• Use of the nursing process


  Allows nurses to help patients meet agreed-on outcomes for better health
• Nursing process


  A systematic, rational method of planning and providing individualized nursing care
• Purpose of the nursing process

  To identify client's health status, actual or potential health problems or needs to establish plans to meet the identified needs and to deliver specific nursing interventions to address those needs
• Nursing process


  • Cyclical that is, its components follow a logical sequence, but more than one component may be involved at one time
  • At the end of the 1st cycle, care may be terminated if goals are achieved or the cycle may continue with reassessment, or the plan of care may be modified
• Nursing process


  A framework for providing, professional quality care
• Critical thinking is a vital tool for nurse with regard to the nursing process
• Nursing process originated its terms from Lydia Hall


  1955
• Nursing process originated its terms from Johnson


  1959
• Nursing process originated its terms from Orlando

  1961
• Nursing process originated its terms from Wiedenbach


  1963
• Nursing process gained additional legitimacy when it was included in the ANA-Standard of Nursing Practice


  1973
• North American Nursing Diagnosis Association (NANDA) added the nursing diagnosis


  1974
• Nursing practice before nursing process

  • Nursing care was based on medical orders by the physician
  • Focused on specific disease condition rather than on the person being cured for
  • Nursing rendered were often guided by intuition rather than a scientific method
• Characteristics of nursing process

  • Cyclic and dynamic nature
  • Client centered
  • Focus on problem solving and decision making
  • Interpersonal and collaborative
  • Applicable universally
  • Use of critical thinking and clinical reasoning
• Assessment


  Collecting, organizing, validating and documenting client data
• Purpose of assessment


  To establish a database about the client's response to health concerns or illness and the ability to manage health care needs
• Initial assessment


  Performed within specified time after admission to health care agency to establish a complete database for problem identification, reference and future comparison
• Problem-focused assessment


  Ongoing process integrated with the nursing process, focusing on a particular need or health care problem to determine the status of a specific problem identified in an earlier assessment
• Emergency assessment


  During any physiologic or psychologic crisis of the client to identify life threatening problems, to identify new or overlooked problems
• Time-lapsed reassessment


  Done several months after initial assessment to compare the client's current status to baseline data previously obtained
• Data collection


  The process of gathering information about a client's health status, must be both systematic and continuous to prevent omission of significant data and reflect a client's changing health status
• Database


  Contains all the information about a client, including the past and present health history
• Subjective data


  Referred to as symptoms or covert data, apparent only to the person affected and can be described and verified only by that person (sensations, feelings, values, beliefs)
• Objective data


  Referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard (seen, heard, felt, or smelled)
• Primary source


  The client, the best source of data
• Secondary source


  Support people, family members, friends and caregivers who know the client, client records, health care professionals, nursing literature
• Observing


  Gathering data using the senses, a conscious, deliberate skill that is developed through effort and with an organized approach
• Interview


  Planned communication or a conversation with a purpose (to get or to give information, identify problems or mutual concern, evaluate change, teach, provide support or counselling)
• Directive interview


  Highly structured, the nurse establishes the purpose and controls the interview, frequently used when time is limited to gather and give information
• Nondirective interview


  Rapport building interview, the nurse allows the client to control the purpose, subject matter, and pacing
• Closed questions


  Used in the directive interview, require only "yes" or "no" or short factual answers giving specific information
• Open-ended questions


  Non-directive, invite clients to discover, explore, elaborate, clarify or illustrate their thoughts and feelings
• Leading questions


  Usually closed questions used in directive interview, and thus direct the client's answer, giving client less opportunity to decide whether the answer is true or not
• Examination


  Physical examination or physical assessment using examination techniques (inspection, palpation, percussion and auscultation)
• Organizing data


  Nurse organizes or clusters the information in order to identify areas of strengths and weaknesses
• Validating data


  Ensuring that assessment information is complete, that objective and subjective data agree, and obtaining additional information that may have been overlooked
• Cues


  Subjective or objective data that can be directly observed by the nurse