Chapter 4 The Nursing Process and Ultimate
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Pharmacology
the foundation for the clinical practice of nursing; provides the framework for
consistent nursing actions and involves the use of a problem-solving approach
nursing process
designed to provide a standardized language for reporting and analyzing nursing
care delivery that has been individualized for the patient
nursing classification systems
the seven rights of drug administration:
- right patient
- right drug
- right dose
- right route
- right time
- right indication
- right documentation
ALT
alanine aminotransferase
AST
aspartate aminotransferase
BUN
blood urea nitrogen
LDH
lactate dehydrogenase
a systematic method of working with patients is used to identify four types of
nursing diagnoses:
- actual
- risk/high-risk
- health promotion and wellness
- syndrome
nursing diagnosis type; based on human responses to health conditions and life
processes that exist in an individual, family, or community - supported by
defining characteristics that cluster in patterns of related cues or inferences
actual nursing diagnosis
nursing diagnosis type; a clinical judgment that an individual, family, or
community is more susceptible to the problem than others in the same or a
,similar situation - supported by risk factors that contribute to increased
vulnerability
risk/high-risk nursing diagnosis
nursing diagnosis type; a clinical judgment about an individual, group, or
community in transition from a specific level of wellness to a higher level of
wellness
health promotion and wellness nursing diagnosis
nursing diagnosis type; cluster actual or high-risk signs and symptoms that are
predictive of certain circumstances or events - the causative or contributing
actors for the diagnosis are contained in the diagnostic label
syndrome nursing diagnosis
when the nurse cannot legally order the definitive interventions required under
the presenting circumstances, a _____________________ problem exists
collaborative
the wording of an actual nursing diagnosis:
- patient problem summarizing the issue
- contributing factors or cause, which may include ADLs or the medical diagnosis
- defining characteristics
risk-high-risk nursing diagnosis statements consist of two parts:
- diagnostic label from the NANDA-I approved list
- risk factors that make the individual or group more susceptible to the development of
the problem
health promotion or wellness nursing diagnosis statement is a one-part label
initiated by the words
"readiness for enhanced..."
a collaborative problem statement is worded as a potential complication, which is
abbreviated as
PC (ex: "PC Hypokalemia)
the planning stage of the nursing process encompasses four phases:
- priority setting
- development of measurable goal and outcome statements
- formulation of nursing interventions
- formulation of anticipated therapeutic outcomes that can be used to evaluate the
patient's status
application of data from scientific research to make clinical decisions about the
care of individual patients
evidence-based practice
measures of care that are tracked to show how often hospitals and healthcare
providers use the care recommendations identified by evidence-based practice
standards for patients who are being treated for conditions such as heart attack,
heart failure, and pneumonia or for patients who are undergoing surgery
core measures
starts with an action word that is followed by the behavior or behaviors to be
performed by the patient or the patient's family within a specific amount of time
measurable goal statement
, a comprehensive standardized classification system of patient outcomes that
was developed to evaluate the effect of nursing interventions on patient care
nursing outcomes classification (NOC)
three types of nursing actions within the nursing process:
- dependent
- interdependent
- independent
actions performed by the nurse on the basis of healthcare provider's orders
dependent actions
nursing actions that the nurse implements cooperatively with other members of
the healthcare team for restoring or maintaining the patient's health
interdependent actions
nursing actions that are not prescribed by a healthcare provider that a nurse can
provide by virtue of the education and licensure that he or she has obtained
independent actions
describe how specific actions, including time intervals, will be implemented for
an individual patient
nursing orders
example of nursing interventions for patient with respiratory issues:
(date): cough, turn, deep breathe: 0800, 1000, 1200, 1400, 1600
(date): educate patient re: abdominal breathing, splinting abdomen, pursed-lip
breathing, and assuming correct position to facilitate breathing
with regard to relating the nursing process to the nursing gunctions associated
with medications, assessment includes taking a drug history for three reasons:
- evaluate the patient's need for medication
- obtain his or her current and past use of OTC medications, prescription medications,
herbal products, and street drugs
- identify problems related to drug therapy
the nurse draws on three sources to build the medication-related information
base:
- primary source
- subjective data
- objective data
the etiology and contributing factors are those clinical and personal situations
that can cause the problem or influence its development, situations can be
organized into five categories:
- pathophysiologic
- treatment related
- personal
- environmental
- maturational
priority ranking in preparation for health education may encompass several
factors:
- the patient's concerns, belief system, and priorities
- the urgency or time available for the learning to take place