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103 Cards in this Set
- Front
- Back
Nursing Process
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a systematic problem solving approach toward giving individualized nursing care
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6 steps of Nursing Process
(ADOPIE) |
1. Assessment
2. Diagnosis 3. Outcome Identification 4. Planning 5. Implementation 6. Evaluation |
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Characteristics of Nursing Process
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- It is a framework for providing nursing care to individuals, families, and communities
- It is orderly and systematic - It is interdependent - Provides specific care for individuals, families, and communities - Patient centered, using the patient's strengths - Appropriate for use throughout the lifespan - It can be used in all settings |
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Assessment
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- refers to the evaluation or appraisal of a patient's health state
- The systematic collection of subjective and objective data |
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Primary source
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- the patient themself
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Secondary source
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- family members, significant others, other health care professionals, health records, and literaturereview
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Diagnostic Reasoning
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Process of gathering and clustering data to draw inferences and propose diagnoses
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Diagnosis
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- 2nd phase in nursing process
- The clinical act of identifying problems |
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Nursing Diagnosis
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- describes an individual, family, or group response to an actual or potential health problem
- Provides the basis for selection of nursing interventions to achieve positive patient outcomes |
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Diagnostic Process Steps set by NANDA-I
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1. Recognize the existence of cues
2. Generate possible diagnoses 3. Compare cues to possible diagnoses 4. Conduct a focused data collection 5. Validate diagnoses |
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Critical Thinking
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- a self-guided, self-disciplined thinking that attempts to reason at the highest level of quality in a fair-minded way
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Importance of Critical Thinking in Nursing
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Critical thinking helps nurses to choose solutions or identify options for patient care situations
Takes us through a process in order to make decisions |
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Skills in Providing Care
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Listening
Collaborating Communicating |
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Critical thinking and Examinations
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Interpret
Analyze Outcomes Evaluate Infer Explain |
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According to the ANA Scope and Standards of Practice
Outcome Identification refers to ______? |
- formulating and documenting measurable, realistic, patient-focused goals.
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Critical thinking and Examinations
(ADOPIE) |
A - Interpret
D- Analyze O- Outcome P- Evaluate I- Infer E- Explain |
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Interpret
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- Ask relevant questions and explore ideas
- Validate data - Recognize issues and concerns |
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Analyze
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- Interpret evidence
- Consider viewpoints and recognize assumptions - Identify missing information |
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Outcome
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- Results that are measurable and observable
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Evaluate
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- Detect bias
- Consider legal/ethical standards - Use reflective skepticism - Examine alternatives - Judge worth of evidence |
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Infer
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- Predict consequences
- Apply deductive/inductive reasoning - Support conclusions with evidence - Set priorities - Plan approaches - Modify/ individualize interventions - Apply research in practice |
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Explain
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- Determine outcome attainment
- Revise Plans - Identify client's perception of results |
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Assessment is done for what reasons?
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- to establish baseline info. on the patient
- To determine the patient's normal function - the patients risk of dysfunction - the patient's strengths - To provide data for the diagnosis phase |
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The following activities make up the assessment phase:
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- Collection of Data
- Validation of Data - Organization of Data |
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4 Types of Assessment
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1. Admission Assessment
2. Focus Assessment 3. Time-Lapse Assessment 4. Emergency Assessment |
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Admission Assessment
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- Initial identification of normal function, functional status, and collection of data concerning actual or potential dysfunction
- baseline for reference and future comparison |
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Focus Assessment
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- Status determination of a problem identified during previous assessment
- Ongoing process, few minutes to a few hours |
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Time-lapse Assessment
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- Comparison of patient's current status to baseline obtained earlier
- 3,6, or 9 months between assessments |
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Emergency Assessment
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- Identification of life-threatening situation
- Occurs anytime a physiologic, psychological, or emotional crisis occurs |
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Assessment Skills
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- Observation
- Interviewing - Physical Examination |
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Observation includes:
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- Vision - Objective
- Smell - Objective - Hearing - Sub. and Objective - Touch - Objective |
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4 Phases of Interviewing
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Preparatory phase
Introductory phase Maintenance phase Concluding phase |
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Physical examination techniques
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Inspection
Palpation Percussion Auscultation |
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Observation is:
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- The act of noticing patient cues
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Interviewing is:
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- Integration and communication process for gathering data by questioning and information exchange
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Physical Examination is:
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- Analysis of bodily functioning using the techniques of inspection, palpation, percussion, and auscultation
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Definitions for Classification of Nursing Diagnoses
(Domain) |
A sphere of activity, concern, or function; a field: the domain of history
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Definitions for Classification of Nursing Diagnoses
Class |
A set, collection, group, or configuration containing members regarded as having certain attributes or traits in common; a kind or category.
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Nursing diagnoses and other healthcare problems
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Nursing diagnosis
Medical diagnosis Collaborative health problems |
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Components of a Nursing Diagnosis
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Diagnostic label
Descriptors Definition Related factors Defining characteristics Risk factors |
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Descriptors Used by NANDA-I
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Anticipatory
Compromised Decreased Deficient Delayed Disproportionate Disabled Disorganized Disturbed Dysfunctional Effective Excessive |
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Diagnosis Activities
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Identify pattern
Validate diagnosis Formulate the diagnostic statement |
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Diagnosis Activities
Identify pattern |
Cue clustering
Problems in cue clustering Cluster interpretation Problems in cluster interpretation |
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Diagnosis Activities
Validate diagnosis |
Problems in diagnostic validation
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Diagnosis Activities
Validate diagnosis |
Problems in diagnostic validation
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Diagnosis Activities
Formulate the diagnostic statement |
Actual nursing diagnosis
Risk nursing diagnosis Wellness nursing diagnosis Possible nursing diagnosis |
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3 types of nursing Diagnoses
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- Actual Nursing Diagnosis
- Risk Nursing Diagnosis - Wellness Diagnosis |
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Actual Nursing Diagnosis
(3 Parts) |
- Diagnostic Label
- Related Factors (etiology) - Defining Characteristics (signs and symptoms) |
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Example of an Actual Nursing Diagnosis
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Stress Urinary Incontinence R/T
weak pelvic muscles, obesity, and gravid uterus as evidenced by urine dribbling when coughing |
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Risk Diagnosis
(2 parts) |
- Diagnostic label R/T
- Risk factors |
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Example of Risk Diagnosis
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- Risk for Caregiver Role Strain R/T
discharge of family member with significant health needs, economic instability, lack of respite care availability |
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Wellness Diagnosis
(1 Part) |
- Diagnostic Label
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Example of Wellness Diagnosis
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- Potential for Enhanced Parenting
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Functional Health Patterns of Nursing Diagnosis
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- Health Perception- Health Management
- Activity-Execise - Nutritional-Metabolic - Elimination - Sleep-Rest - Cognitive-perceptual - Self-Perception - Role-Relationship - Coping-stress Tolerance - Sexuality-Reproductive - Value-Belief |
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Outcome Identification
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- is the formulation of goals and measurable outcomes that provide the basis for evaluating nursing diagnoses
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Outcome Identification
Purposes |
Providing individualized care
Promoting patient participation Planning care that is realistic and measurable Allowing for involvement of support people |
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Outcome Identification
Activities |
Establish priorities
Establish patient goals and outcome criteria |
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Outcome Identification Activities
3 Priorities Established |
High priority
Medium priority Low priority |
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High Priority Nursing Diagnosis
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- Any Life threatening situation
needs immediate attention |
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Medium Priority Nursing Diagnosis
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- involve problems that could result in unhealthy consequences such as physical or emotional impairment, but are not likely to threaten life
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Low Priority Nursing Diagnosis
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- involve problems that usually can be resolved easily with minimal interventions and have little potential to cause significant dysfunction
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Nursing Outcomes Classification
(NOC) are organized how? |
- Organized according to categories, classes, labels, outcome indicators, and measurement activities for outcomes
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Outcome Identification
Objectives |
- Establish priorities
- Establish client goals and outcome identification |
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A patient outcome is
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- an educated guess, made as a broad statement, about what the patient's state will be after the nursing intervention is completed
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Qualifier
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- description of the parameter for achieving the outcome
ex. "Ambulates safely with one-person assistance" |
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Outcomes may be ____ or ____?
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- short-term or Long-term
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Outcome criteria
3 characteristics of |
Specific, measurable, realistic
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Outcome criteria answer the questions ____, ____, ____, ____, and ____?
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- Who; what actions; under what circumstances; how well; and when
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Requirements for outcome criteria are....
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- Subject: Who is the person to achieve the goals
- Verb: What actions must the person do to achieve the goals - Condition: Under what circumstances is the person to perform the action? - Criteria: How well is the person to perform the action? - Specific Time: When is the person expected to perform the action? |
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Purposes of Planning include ???
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- Direct patient care activities
- Promote continuity of care - Focus charting requirements - Allow for delegation of specific activities |
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Planning is the ___ phase of of the nursing process?
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- 4th
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Def of Planning
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-refers to the development of nursing strategies designed to ameliorate patient problems
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Nursing Intervention Classification
(NIC) are organized in three level taxonomy consisting of ???? |
- domains, classes, and interventions
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Taxonomy of NIC includes these 7 domains???
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1. Physiologic: Basic
2. Physiologic: Complex 3. Behavioral 4. Safety 5. Family 6. Health system 7. Community |
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Each NIC domain contains
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- classes which are groups of interventions that are broken down into individual interventions.
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Planning nursing interventions
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Any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient outcomes
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Types of Nursing Interventions Include
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Psychomotor- Technical
Psychological- Interpersonal Educational- Cognitive Maintenance-Technical Surveillance- Technical Supervisory- Cognitive Sociocultural- Interpersonal |
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Psychomotor Interventions
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- positioning, inserting, applying
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Psychological
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Interpersonal
supporting, exploring, encouraging |
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Educational
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Cognitive
demonstrating, teaching, observing return demonstrations |
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Maintenance
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Technical
skin care, hygiene |
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Surveillance
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Technical
detecting changes |
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Supervisory
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Cognitive
other healthcare providers |
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Sociocultural
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Interpersonal
spending time, incorporating cultural differences into care regimen |
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Writing a patient plan of care must be
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Patient centered
Step-by-step process |
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A patient plan of care documents
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- the problem solving process.
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Patient care Plans must be
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- written by a RN
- be documented in the patients health record - must reflect the standards of care established by the institution and profession |
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Two important concepts guide a patient plan of care. They are:
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- the care plan is patient centered
- The plan of care is a step by step process |
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Writing a patient plan of care
Step-by-step process is evidenced by |
- sufficient data are collected to sustantiate nursing diagnosis
- at least one goal must be stated for each nursing diagnosis - Outcome criteria must be identified for each goal - Nursing interventions must be specifically designed to meet the intended goal - Each intervention should be supported by scientific rationale - Evaluation must address whether each goal was completely met, partially met, or completely unmet |
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3 Types of Patient Plans of Care
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Instructional patient plans of care
Instructional concept maps Clinical plans of care |
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Types of Clinical Plans of Care
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Individual Plan of Care
Standardized Plan of Care Generic Plan of Care Computerized Plan of Care |
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Instructional patient plans of care
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- allow students to demonstrate their knowledge of a variety of patient problems and apply the processes nurses use to solve them
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Components of instructional patient plans of care
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- nursing diagnoses
- patient goals - outcome criteria, - nursing interventions - scientific rationale - evaluation |
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Individual Plan of Care
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- Written for each patient by an RN
- Nursing Diagnoses are listed - Specific Goals and interventions to resolve the problem - Time consuming |
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Standardized Plan of Care
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- Written by groups of Nurses who are experts in a given area of practice
- Written for a patient population with specific medical diagnosis |
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Generic Plan of Care
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- Written for specific nursing diagnosis
- Contain the most commonly seen goals and interventions for a particular nursing diagnosis |
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Computerized Plan of Care
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- generated from assessment data entered into a computer about a specific patient
- Written by experts in the area - Nurse may customize for the patient once on the screen - All patient info must be entered into the computer |
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Implementation Activities of implementation
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Reassessing
Setting priorities Performing nursing interventions Recording nursing actions |
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Implementation refers to
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- the action phase of the nursing process
- It is the actual initiation of the plan and recording the of nursing actions |
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Intellectual skills used in implementation are
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- problem solving
- decision making - and teaching |
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Interpersonal skills used in implementation
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- Verbal and nonverbal communication skills
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Priorities are set based on what factors
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- The patient's condition
- New information from reassessment - Time and resources available for nursing interventions - Feedback from the patient, family, and healthcare staff - The nurse's experience in assessing situations and setting priorities |
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Advantages to NIC
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- Creation of a standardized language that promotes better understanding and communication of nursing interventions
- Expansion of knowledge about similarities and differences across nursing diagnoses - Exploration of nursing care information systems - Assistance in determining cost of services that nurses provide - Demonstration of the impact nurses have within the healthcare system |