| Types of data: | Subjective and objective data |
| Types of data: | Subjective and objective data |
| Is the process of intentional higher level thinking to define a client's problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care. | Critical thinking |
| What separates nurses from technicians? | Clinical judgment |
| Is the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of the information, and decide on possible nursing actions to improve the client's physiological and psychosocial outcomes | Clinical reasoning |
| Nurses use knowledge from other subjects and fields
Nurses deal with change in stressful environments
Nurses make important decisions.
Critical thinking cognitively fuels the intellectual artistic activity of creativity | Purpose of critical thinking |
| Techniques in critical thinking: | Critical analysis
Socratic questioning
Inductive reasoning |
| Socratic questions: Questions about | The decision (or problem)
Assumptions
Point of view
Evidence and reasons
Implications and consequences |
| Is a mental activity in which a problem is identified that represents an unsteady state. | Problem-solving process |
| Commonly used approaches in problem-solving process | Trial and error
Intuition
Research process
Scientific method |
| Independence
Fair-mindedness
Insight into Egocentricity
Intellectual humility
Intellectual Courage to Challenge the Status Quo and Rituals
Integrity
Perseverance
Confidence
Curiosity | Attitudes that foster critical thinking |
| Components of clinical reasoning | Setting priorities
Developing rationales
Learning how to act
Clinical Reasoning-in-transition
Responding to Changes in the Client's Condition
Reflection |
| The decision-making process includes prioritizing care not only with ??? but when providing ??? | The decision-making process includes prioritizing care not only with one client but when providing care to many clients. |
| Nurses must make ??? and also ??? to make decisions | Nurses must make decisions and also assist clients to make decisions |
| Is a systematic, rational method of planning and providing individualized nursing care
The client may be an individual, a family, a community, or a group | The Nursing Process |
| Five-Step Nursing Process: | 1 Assess
2 Diagnose
3 Plan
4 Implement
5 Evaluate |
| Five-Step Nursing Process: 1: Gather information about the patient's condition | Assess/ assessment |
| Five-Step Nursing Process: 2: Identify the patient's problems | Diagnose |
| Five-Step Nursing Process: 3: Set goals of care and desired outcomes and identify appropriate nursing actions | Plan |
| Five-Step Nursing Process: 4: Perform the nursing actions identified in planning | Implement |
| Five-Step Nursing Process: 5: Determine if goals and expected outcomes are achieved | Evaluate |
| Cyclic and dynamic nature
Client centeredness
Focus on problem-solving and decision-making
Interpersonal and collaborative style
Universal applicability
Use of critical thinking | Characteristics of the Nursing Process |
| Involves collecting information from the patient and from secondary sources (e.g., family members), along with interpreting and validating the information to form a complete database. | Assessment |
| Activities during Assessment/ stages of assessment: | Collecting data
Organizing data
Validating data
Documenting data |
| Stages or types of assessment: Performed within specified time after admission to a health care agency
Purpose: To establish a complete database for problem identification, reference, and future comparison
Example: Nursing admission assessment | Initial assessment |
| Stages or types of assessment: Ongoing process integrated with nursing care
Purpose: To determine the status of a specific problem identified in an earlier assessment
Example: Hourly assessment of client's fluid intake and urinary output in an ICU | Problem-focused assessment |
| Stages or types of assessment: During any physiological or psychological crisis of the client
Purpose: To identify life-threatening problems
To identify new or overlooked problems
Examples: Rapid assessment of an individual's airway, breathing status, and circulation during a cardiac arrest assessment of the patient or potential hazard keme | Emergency assessment |
| Stages or types of assessment: Several months after initial assessment
Purpose: To compare the client's current status to baseline data previously obtained
Example: ikaw na maghuna huna no? HAHAHAHHA nasalipdan man maong wala | Time-lapsed assessment |
| Components of a Nursing Health History | Biographic data
Chief complaint or reason for visit
History of present illness
Past history
Family history of illness
Lifestyle
Social data
Psychological data
Patterns of health care |
| Sources of data: | Primary and secondary sources of data |
| Sources of data: Patient (interview, observation, physical examination) - the best source of information | Primary source |
| Sources of data: Family and significant others (obtain patient's agreement first)
Health care professionals
Client records
Scientific literature
Database | Secondary soucrce |
| Types of data: | Subjective and objective data |
| Types of data: Symptoms
Example: "I'm not really feeling crummy. Nothing is going my wat."
"I've never had pain like this" | Subjective data |
| Types of data: Signs
Examples: Three-inch diameter circle of red drainage through three 4x4 dressings at incision site.
Ate 120 mL orange juice, toast, egg, and coffee | Objective data |
| Methods of data Collection: | 1 Observing
2 Interview
3 Examination |
| Methods of data Collection: 1: Gathering data using the senses | Observing |
| Methods of data Collection: 2: Planned communication or a conversation with a purpose | Interview |
| Methods of data Collection: 3: Systematic data-collection method | Examination |
| Frameworks for Nursing Assessment: | Nursing models framework
Wellness models
Non-nursing Models |
| Frameworks for Nursing Assessment: Nursing Models Framework: | Gordon's functional health pattern framework
Oren's self-care model
Roy's adaptation model |
| Frameworks for Nursing Assessment: Non-nursing Models | Body systems model
Maslow's Hierarchy of Needs
Developmental theories |
| A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community
Provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability | Nursing diagnosis |
| Kinds of Nursing Diagnoses according to status: | 1 Actual diagnosis
2 Health Promotion nursing diagnosis
3 Risk nursing diagnosis
4 Syndrome diagnosis |
| Kinds of Nursing Diagnoses according to status: 1: Client problem that is present at the time of the nursing assessment | Actual diagnosis |
| Kinds of Nursing Diagnoses according to status: 2: A health promotion diagnosis relates to client's preparedness to implement behaviors to improve their health condition | Health Promotion nursing diagnosis |
| Kinds of Nursing Diagnoses according to status: 3: Is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervenes | Risk nursing diagnosis |
| Kinds of Nursing Diagnoses according to status: Is assigned by a nurse's clinical judgment to describe a client's nursing diagnoses that have similar interventions | Syndrome diagnosis |
| Components of a Nursing Diagnosis: | 1 Problem statement
2 Etiology
3 Defining characteristics |
| Components of a Nursing Diagnosis: 1: describes the client's health problem or response | Problem statement (diagnostic label) |
| Components of a Nursing Diagnosis: 2: Identifies one or more probable causes of the health problem | Etiology |
| Components of a Nursing Diagnosis: 3: Cluster of signs and symptoms indicating the presence of a particular diagnostic label (actual diagnoses)
Factors that cause the client to be more vulnerable to the problem (risk diagnoses) | Defining characteristics |
| Readiness for Enhanced Self-Esteem
Readiness for enhanced spiritual well being
Readiness for enhanced family copin | Health-promotion nursing diagnosis |
| Ineffective breathing pattern related to bacterial / viral inflammatory process
Ineffective breathing pattern related to Tracheo-bronchial obstruction
Anxiety related to changes in the environment and routines, threat to socio economic status
Anxiety related to change in health status and situational crisis
Body image disturbance related to temporary presence of a visible drain/tube | Examples of Actual Nursing Diagnosis |
| Risk for impaired skin integrity related to immobility
Risk for impaired skin integrity related to edema and neuropathy
Risk for injury related to generalized weakness
Risk for Impaired skin integrity (left ankle) related to decrease peripheral circulation in diabetes
Risk for Impaired skin integrity related to loss of pa??? perception
Eg. Admission in hospital prone for acquiring infection-compromised immune system
1 Risk for infection related to compromised immune system
2 Risk for injury related to altered mobility and disorientation
3 Risk for aspiration related to decreased cough and reflex | Examples of risk nursing diagnosis |
| Rape-trauma syndrome related to anxiety about potential health problems and as manifested by anger, genitourinary discomfort, and sleep pattern disturbance | A syndrome diagnosis |
| Eg. Disuse syndrome includes: | Impaired physical mobility
Impaired gas exchange
Risk for tissue
Impaired integrity
Risk for activity intolerance
Risk for constipation
Risk for infection
Risk for injury
Risk for powerlessness |
| nanda modifiers: sever, serious, intense, critical | Acute |
| nanda modifiers: Constant, persisting, ever present | Chronic |
| nanda modifiers: exhausted, tired, useless | Depleted |
| nanda modifiers: troubled, uneasy, unbalanced, bothered | Disturbed |
| nanda modifiers: Inability to function, organ or parts of body unable to function | Dysfunctional |
| Are words that have been added to some NANDA labels to give additional meaning to the diagnostic statement | Qualifiers |
| NANDA modifiers or qualifiers: inadequate in amt, quality, or degree, not sufficient, Incomplete | Deficient |
| NANDA modifiers or qualifiers: made worse, weakened, damaged, reduced, Deteriorated, Absent, lessened, either temporarily or permanently | Impaired |
| NANDA modifiers or qualifiers: Distorted, changed | Altered |
| NANDA modifiers or qualifiers: Chance of something going wrong, hazard, damage, something likely to cause injury, something to harm, danger, or loss | Risk for |
| NANDA modifiers or qualifiers: Reduce, lessen, decline, diminution, lesser in size, amount or degree | Decreased |
| NANDA modifiers or qualifiers: Not producing the desired coping, unproductive, unsuccessful, useless | Ineffective |
| NANDA modifiers or qualifiers: to make vulnerable to threat | Compromised |
| NANDA modifiers or qualifiers: Improved, better | Enhanced |
| NANDA modifiers or qualifiers: Extreme, too much, unnecessary, disproportionate | Excessive |
| NANDA modifiers or qualifiers: greater than before, improved | increased |
| NANDA modifiers or qualifiers: irregular, alternating ,discontinuous | Intermittent |
| NANDA modifiers or qualifiers: likely to occur, may or might | Potential for |
| Nursing Diagnosis, Medical Diagnosis, and Collaborative Problems Differences based on: | Description
Orientation
Responsibility for diagnosing
Treatment orders
Nursing focus
Nursing actions
Duration
Classification system |
| Describes human responses to disease processes/ health problems
Oriented to the client
Nurse responsible for diagnosing, treatment orders, actions | Nursing diagnosis |
| Describes disease and pathology
Oriented to pathology
Physician responsible for diagnosing and treatment orders | Medical diagnosis |
| Physiologic complications of disease, tests, treatments
Oriented to pathophysiology
Nurse and physician diagnose
Physician orders definitive treatment | Collaborative problems |
| Steps in Diagnostic Process: 1: Compare data against standards
cluster cues
Identify gaps and inconsistencies | Analyzing data |
| Types of cue: Comparing Cues to Standards and Norms:
Client cues: Height is 158cm (5 ft. 2 in.) Woman with small frame. Weighs 109 kg (240lb).
Standard/Norm: Height and weight tables indicate that the "ideal" weight for a woman 158 cm (5 ft. 2 in.) with a small frame is 49-53 kg (108-121 lb). | Deviation from population norms |
| Types of Cue: | Deviation from population norms
Developmental delay
Changes in client's usual health status
Dysfunctional behavior
Changes in client's usual behavior |
| Types of cue: Comparing Cues to Standards and Norms:
Client cues: Child is 17 months old. Parents state child has not yet attempted to speak. Child laughs aloud and makes cooing sounds
Standard/Norms: Children usually speak their first word by 10-12 months of age | Developmental delay |
| Types of cue: Comparing Cues to Standards and Norms:
Client cues: States "I'm just not hungry these days." Ate only 15% of food on breakfast tray. Has lost 13 kg (30 lb) in past 3 months.
Standard/Norm: Client usually eats three balanced meals per day. Adults typically maintain stable weight. | Change in client's usual health status |
| Types of cue: Comparing Cues to Standards and Norms:
Client cues: Amy's mother reports that Amy has not left her room for 2 days. Amy is age 16. Amy has stopped attending school and has withdrawn from social contact
Standard/Norm: Adolescents usually like to be with their peers; social group very important. Functional behavior includes school attendance | Dysfunctional behaviors |
| Types of cue: Comparing Cues to Standards and Norms:
Client cues: Mrs. Stuart reports that lately her husband angers easily.
"Yesterday he even yelled at the dog." "He just seems so tense"
Standard/Norm: Mr. Stuart is usually relaxed ???. He is friendly and kind to ??? | Changes in client's usual behavior |
| Steps in Diagnostic Process: 2: | Identifying health problems, risks, and strengths |
| Steps in Diagnostic Process: 3: | Formulating diagnostic statements |
| State in terms of a problem, not a need.
Word the statement so that it is legally advisable
Use nonjudgmental statements
Make sure that both elements of the statement do not say the same thing
Be sure that cause and effect are correctly stated.
Word the diagnosis specifically and precisely
Use nursing terminology rather than medical terminology to describe the client's response and probable cause of client's response | Guidelines for Writing a Diagnostic Statement |
| Components of Nursing Diagnoses: Basic Two(; Three) -Part Statement: | 1 Problem statement or diagnostic label
2 Etiology (; Three)
3 Defining characteristics |
| Have diagnostic labels
Consist of the diagnostic label plus etiology
Professional nurses responsible for making nursing diagnoses
A judgment made only after thorough, systematic data collection
Describes a continuum of health states | Characteristics of a Nursing Diagnosis |
| Is a deliberative, systematic phase of the nursing process that involves decision making and problem solving.
Begins with first client contact
Continues until nurse-client relationship ends (discharge)
Multidisciplinary | Planning |
| Types of planning | Initial planning
Ongoing planning
Discharge planning |
| Standards of care
Standardized care plans
-Individualization of Standardized Care plans
Protocols
Policies and procedures | Standardized plans |
| Date and sign the plan
Use category headings
Use standardized/ approved medical or English symbols and Key words
Be specific
Refer to procedure book or other sources rather than including steps
Tailor the plan to the client
Incorporate prevention and health maintenance
Include interventions for ongoing assessment
Include collaborative and coordination activities
Include discharge plans and home care | Guidelines for Writing Nursing Care Plans |
| The Planning Process | 1 Setting priorities
2 Establishing client goals/desired outcomes
3 selecting nursing interventions
4 Writing individualized nursing interventions on care plans |
| Setting priorities | a. life-threatening situations should be given highest priority
b. use the principle of ABC's
c. use Maslow's hierarchy of needs
d. consider something that is very important to the client
e. clients with unstable condition over those with stable conditions
f. consider the amount of time, materials, equipments required to care for clients
g. Actual problems take precedence over potential concerns
h. Attend to the client before equipment
i. Consider the Nursing diagnoses |
| An educated guess, made as a broad statement, about what the client's state will be after the nursing intervention is carried out.
May be short-term or long-term | Client goals or goals |
| Written in a manner that they answer the questions: who, what actions, under what circumstances, how well, and when.
S - pecific
M - easurable
A - ttainable
R - ealistic for the individual patient situation
T - ime-bounded
E - valuation
R - eimplementation/Reevaluation (?) | Desired outcome |
| Goal: The client will report a decreased anxiety level regarding surgery
Possible Outcome Criteria: During client teaching, the client discusses fears and concerns regarding surgical procedure
After client teaching, the client verbalizes decreased anxiety.
The client identifies a support system and strategies to use to recover and anxiety related to the surgical experience | Examples of goals and outcome criteria |
| Goal statements:
Example: The patient will select 3 days' menus by 10/6 Using diabetic diet exchange | Subject + Verb + Criteria + Condition, if relevant |
| Actions nurse performs to achieve goals/desired outcomes
Focus on eliminating or reducing etiology of nursing diagnosis
Treat signs and symptoms and defining characteristics | Nursing intervention |
| Types of nursing interventions: | Independent, dependent and collaborative interventions |
| Safe and appropriate for the client's age, health, and condition
Achievable with the resources available
Congruent with the client's values, beliefs, and culture
Congruent with other therapies
Based on nursing knowledge and experience or knowledge from relevant sciences
Within established standards of care | Criteria for choosing Appropriate Interventions |
| Consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions | Implementation |
| Successful implementation: To implement care successfully, nurses need: | Cognitive skill
Interpersonal skills
Technical skills |
| Process of Implementing: | Reassessing the client
Reviewing and Revising the Existing Nursing Care Plan
Preparing for Implementation
-Time management
-equipment
-Personnel
-Environment
-Patient |
| Activities of Daily Living
Instrumental Activities of Daily Living
Physical Care Techniques
Life Saving Measures
Counseling
Teaching
Controlling for Adverse Reactions
Preventive Measures | Direct Care |
| Communication of Nursing Interventions
Delegating, Supervising and Evaluating the Work of Other Staff Members | Indirect Care |
| Is a planned, ongoing, purposeful activity in which clients and health care professionals determine:
The client's progress toward achievement of goals/outcomes
The effectiveness of the nursing care plan | Evaluating |
| Components of the Evaluation Process: | 1-5 |
| Components of the Evaluation Process: 1 | Collecting data related to the desired outcomes (NOC indicators) |
| Components of the Evaluation Process: 2 | Comparing the data with outcomes |
| Components of the Evaluation Process: 3 | Relating nursing activities to outcomes |
| Components of the Evaluation Process: 4 | Drawing conclusions about problem status |
| Components of the Evaluation Process: 5 | Continuing, modifying, or terminating the nursing care plan |
| maintaining confidentiality of records | Restrict access
Ethical codes and legal responsibility
Policies and procedures to ensure privacy and confidentiality |
| The process of making an entry on a client record; charting, recording | Documentation |
| Passwords required and should not be shared
Never leave the computer terminal unattended after logging on
Do not leave client information displayed
Shared all unneeded computer-generated worksheets
Know the facility's policy and procedure for correcting an entry error
Follow agency procedures for documenting sensitive material
Firewalls | Security for Computerized Records |
| purposes of Clients Records | Communication
Planning client care
Auditing health agencies
Research
Education
Reimbursement
Legal Documentation
Health care analysis |
| Date and Time
Timing
Legibility
Permanence
Accepted terminology
Correct spelling
Signature
Accuracy
Sequence
Appropriateness
Completeness
Conciseness
Legal prudence | Factors to consider |
| Admission Nursing Assessment
Nursing Care Plans
Kardexes
Flow Sheets
-Graphic record
-intake and output record
-Medication Administration record
-skin assessment record
Progress Notes
Nursing Discharge/Referral summaries | Documenting Nursing Activities |
