Nursing Process NUR 307
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This 7 page Study Guide was uploaded by Alissa Notetaker on Friday October 2, 2015. The Study Guide belongs to NUR 307 at La Salle University taught by in Fall 2015. Since its upload, it has received 10 views. For similar materials see Foundations of Practice in Nursing and Health Sciences at La Salle University.
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Date Created: 10/02/15
Nursing Process 09242015 1 ASSESS Objective Data something you can measure Temperature Bruises Assigning number to pain Subjective What the client says Nauseous Pain 2 Diagnoses Patient Problem ex Renal Failure Hypertension 3 Goals and Outcomes Pt will not fall this shift Pt will understand medications by discharge 4lnterventionslmplementations Nurse will medicate patient with Tylenol Nurse will teach side effects of Lisinopril Nurse will obtain dietician consult 5Evaluation Was our care effective If not then why Critical thinking Look at sources of data during assessment Chest xray ultra sound High BP high sodium Ect Does any of this data cluster Then we start asking questions Data base Everyone will have a data base which will be entered when admitted by admitting nurse As you collect information you can add to that data base Data collection Sources of data Patient interview observation physical examination the best source of information Family and signi cant others obtain patient s agreement rst Health care team Medical records Scienti c literature Nurse s experience Subjective vs objective data Comprehensive Assesment Approaches Tell me about your health Activity pattern do you exercise Sleep how much sleep do you get at night Cognition Any problems with memory Stress Under any stress Religion amp Spiritual beliefs Clustering Cues guarding wincing crying grimacing What you observe what youre told and your physical assessment give you cues Leading to your decision This pt might be in pain Methods of Data Collection Make sure it s a good time to talk to the patient f theyre watching a tv show or having a meal or have family Not good times Sometimes family is good because they can help Give patient about how long it is going to take Interviewing Techniques Open vs Closed questions Closed end Are you having pain Open end Can you tell me a bit about your pain Ask people how they describe their problems Cultural Considerations If youre not sure what a patient is saying make sure you know what they are talking about Document what you nd Look at Blood works ekgs diagnostic tests as next assessment steps Collect cluster and inference the data Collaborative intervention Paint pt Contact Physician to get a medication order Trouble Breathing Contact physician for 02 order and respiratory team comes in Problemimpaired physical mobility Related to incision pain Symptoms patient not wanting to get out of bed or turn Medical diagnosis not nursing diagnosis Identify patients problem rather than your problems with nursing care Ex patient is anxious because they are annoying me with call be That is not a symptom of anxiety Establishing Priorities Ex problems Knowledge Defecit l3 NDx Readiness to Learn Ineffective Airway Clearance Main Priority 1 Nuer Pain 2 Nuer Pt has chronic emphysema Pt is a lot of pain Pt states he is ready to learn about about quitting smoking Pt states they know they have to quit smoking Risk for problem and known problem which has more priority Depends Risk for Ineffective Airway Clearance and Known Knowledge defecit Airway clearance is probably more important Goals Patient centered Measurable ReaHsUc Types of Interventions Nurse Initiated do not need permission Physician Initiated amp Collaborative when you need another party to put an intervention Clarifying an Order If you read an order and don t get it call the writer of the order Sometimes other departments will go in and write things on patients chart CHANGE OF SHIFT Face to face SBAR Communication Type of communication Make sure you know what the nurse says during each part SSituation this is the patient this is whats going on now BBackground this is the patients back ground AAssessment this is their head to toe assessmen RReccomendations what you think should be done Concept Maps Some interventions over lap Consulting other Practices Doctors Dieticians Phys Ther Social Work Occup Ther Spiritual Guidance Certain specialties of nurses midwife woundcare nurse Nursing Interventions Its what the nurse doesll Protocols and Standing Orders Modi cation of an Existing Written Care Plan What to do when your goal isn39t effective Did I collect the right data Was my goal or outcome realistic Were my interventions appropriate Direct Interventions Indirect Interventions
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