Nursing_Process_Admit_Ticket.docx.pdf

Describe the difference between a medical assessment and a nursing assessment. Medical assessments require a physician, and it is leads to a diagnosis based on pathological conditions, which the physician understands, ...

Describe the difference between a medical assessment and a nursing assessment. Medical assessments require a physician, and it is leads to a diagnosis based on pathological conditions, which the physician understands, defines, and treats. Nursing assessments focus on how the patient responds to the actual or potential health problem such as if the patient has any limitations and can meet their basic needs. Maslow’s Hierarchy of Needs – describe each level Self-Actualization: need to reach full potential; each lower level must be met for this level to be met; continues throughout life; focus on strengths not problems Self Esteem: need to feel good, a sense of pride and accomplishment, and respected/appreciated by those around them; altered when a person’s role changes or when body image changes Love & Belonging: understanding and acceptance in giving and receiving love; feeling of belonging to something such as a group; may lead to depression and isolation if unmet Safety & Security: physical and emotional components; protection from potential/actual harm and trusting others without fear, anxiety, or apprehension Physiologic: includes need for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest; needs to be met to minimally maintain life; most essential and highest priority Self Act uali zati on Self Esteem Love & Belonging Safety & Security Physiologic This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com 2. Nursing Diagnosis vs Medical Diagnosis – describe the focus of each Nursing Diagnosis - actual or potential health problems that can be prevented or resolved by independent nursing interventions; provide basis for selecting nursing interventions Medical Diagnosis – problems for which the physician directs the primary treatment Parts of Nursing Diagnosis Statements - label and define each component Problem – describes the health state or health problem Etiology – identifies what is causing the problem which can be physiological, psychological, sociological, spiritual, or environmental; directs nursing interventions Defining characteristics- signs and symptoms that the patient is exhibiting; can be objective or subjective; signal the existence of the actual or potential health problem 3. Outcome Identification & Planning Outcomes are categorized according to the type of change needed by a patient. Define each type of outcome:  Cognitive –increase in patient knowledge or intellectual behavior  Psychomotor – achievement of a new skill  Affective – changes in patient values, beliefs, and attitude  Clinical – expected status of health issues at a later point in time; address whether the problem was resolved or improved any  Functional – ability to function in relation to desired usual activities  Quality of life – key factors that affect someone’s ability to enjoy life and achieve goals Writing Patient-Centered Measurable Outcomes – describe the characteristics of a measurable outcome  Subject: patient or part of the patient  Verb: states the action the patient will perform o Define, list, explain, prepare, verbalize, select, identify, describe, apply, design, choose, and demonstrate  Conditions: particular circumstance in or by which the patient will achieve the desired outcome This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com  Performance criteria: observable and measurable terms are used to describe the expected patient behavior  Target time: states when the patient is to achieve the outcome o Specific date, before discharge, etc. Nurse Initiated Interventions  Define – autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes  Purpose is to: (list) o monitor patient health status and response to treatment o reduce risks o resolve, prevent, or manage a problem o promote independence with ADLs o promote optimum sense of physical, psychological, and spiritual well being o give patients the information they need to make informed decisions and be independent 4. Implementing the Plan of Care – Describe reasons why a patient may not cooperate with the plan of care:  The patient may not cooperate with the plan of care if he/she: o Has lack of family support o Has lack of understanding about the benefits of the plan of care o Hass low value attached to the outcomes or interventions o Has pain or fatigue o Cannot afford the treatment o Has limited access to the treatment 5. Evaluating:  Define – measuring of how well the patient has achieved the set outcomes specified in the plan of caring by the nurse and patient  Based on the patient’s responses to the plan of care, what can the nurse do to the plan of care? (list 3) o Modify the plan of care if the patient has made little or no progress o Terminate the plan of care if the expected goals were met successfully o Continue the plan of care if the patient appears to be making some improvements Describe actions/responsibilities of the nurse for each of the five classic elements of evaluation: This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com  Identifying Evaluative Criteria and Standards o Design and deliver nursing care that evidence shows will produce the expected outcomes form the patient  Collecting Evaluative Data o Determine whether the patient has met the outcomes or is meeting the desired outcomes  Interpreting and summarizing findings o Consider factors that influence outcome achievement and reinforce the positive variables; requires clinical reasoning  Documenting Your Judgment o Decisions about how well the outcome has been met along with patient data or behaviors that support this decision  Modifying the Plan of Care o Re-evaluate preceding steps to the nursing process, collect new assessment data, modify outcomes and time criteria, change nursing orders and interventions, and evaluate more frequently Nurse Initiated Interventions  Define – autonomous action based on scientific rationale that a nurse executes to benefit the patient in a predictable way related to the nursing diagnosis and projected outcomes  Purpose is to: (list) o monitor patient health status and response to treatment o reduce risks o resolve, prevent, or manage a problem o promote independence with ADLs o promote optimum sense of physical, psychological, and spiritual well being o give patients the information they need to make informed decisions and be independent 4. Implementing the Plan of Care – Describe reasons why a patient may not cooperate with the plan of care:  The patient may not cooperate with the plan of care if he/she: o Has lack of family support o Has lack of understanding about the benefits of the plan of care o Hass low value attached to the outcomes or interventions o Has pain or fatigue o Cannot afford the treatment o Has limited access to the treatment 5. Evaluating:  Define – measuring of how well the patient has achieved the set outcomes specified in the plan of caring by the nurse and patient  Based on the patient’s responses to the plan of care, what can the nurse do to the plan of care? (list 3) o Modify the plan of care if the patient has made little or no progress o Terminate the plan of care if the expected goals were met successfully o Continue the plan of care if the patient appears to be making some improvements Describe actions/responsibilities of the nurse for each of the five classic elements of evaluation: This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com  Identifying Evaluative Criteria and Standards o Design and deliver nursing care that evidence shows will produce the expected outcomes form the patient  Collecting Evaluative Data o Determine whether the patient has met the outcomes or is meeting the desired outcomes  Interpreting and summarizing findings o Consider factors that influence outcome achievement and reinforce the positive variables; requires clinical reasoning  Documenting Your Judgment o Decisions about how well the outcome has been met along with patient data or behaviors that support this decision  Modifying the Plan of Care o Re-evaluate preceding steps to the nursing process, collect new assessment data, modify outcomes and time criteria, change nursing orders and interventions, and evaluate more frequently Refer to Chapter 17 to provide information regarding Erickson’s Developmental Stages Stage Describe Successful Unsuccessful Trust v Mistrust Infant relies on caregiver to meet basic needs. If all needs are provided, the infant learns to trust the caregiver. If needs are inadequate, inconsistent, or not fully met, the infant will develop mistrust. Autonomy v Shame & Doubt Toddler learns from the environment and gains some independence as the caregiver encourages him or her to feed/dress themselves and learn how to use the toilet. If encouraged to do things themselves, toddlers will become autonomous and will grow in independence. If overprotected and not allowed to do such things, toddlers will become shameful and doubtful of what they can accomplish. Initiative v Guilt Preschooler takes initiative to learn, seek out experiences, and understand the how and why of things If encouraged to do things, the preschooler will use gained confidence from being a toddler to take initiative and explore new things If restrictions are placed or the preschooler is reprimanded for taking initiative and trying new things, he or she will hesitate to experience new things again due to the developed guilt. Industry v Inferiority School aged child seeks recognition for achievements If the child gains recognition for accomplishments/achievements, he or she will feel accepted and If the child does not get acceptance/recognition, he or she will feel inferior and This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com appreciated by peers and family. less worthy due to the dismissal by peers and following short of parental approval. Identify v Role Confusion Adolescent is transitioning from childhood to adulthood which is associated with many hormonal changes If the child is allowed to take on roles and some form of rebellion, he or she will be able to get a sense of who they are and what direction they want to take in life. If the child is not allowed to take on roles and some form of rebellion, he or she will become confused in what their role is supposed to be in life leaving them unable to form an identity. Intimacy v Isolation Young adults unite selfidentity with friends in order to make commitments If the young adult can unite selfidentity with friends, they are able to make commitments and form intimate relationships with others. If the young adult is not able to unite self-identity with friends, they will not form intimate relationships resulting in isolation and loneliness. Generatively v Stagnation Middle adults become involved with their family, friends, and community and become concerned with contributing to the world If the middle adult is able to become involved with his or her family and contribute to the world, generativity will result. If the middle adult is not able to become involved with his or her family and contribute to the world, he or she will become stagnate and will focus only on themselves and their needs. Ego Integrity v Despair Older adults reminiscence about life events which may provide a sense of fulfillment and purpose which would provide the older person with a sense of integrity If older adults feel as though their life was filled with many memories and great purposes, they may not fear dying because they see their life as an achievement of integrity. If older adults see their lives as many failures and missed directions, they will feel despaired and a loss of integrity. This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared.Student Name: Jessica Charlie 1. Refer to chapters 11-15 in Taylor’s Fundamentals of Nursing textbook to answer the following questions. Nursing Process Define Purpose Describe nursing activities in this stage Assessment Collect, analyze, validate, and communicate patient data; results in baseline data of the patient Preparing for data collection, collecting data, identifying cues and making inferences, clustering data and identifying patterns, and reporting/recording data Diagnosing Identify how a person responds to actual or potential health and life processes, identify factors that contribute to or cause health problems, and identify resources or strengths that the person can draw on to prevent or resolve problems Creating a list of suspected problems/diagnoses, ruling out similar problems/diagnoses, naming actual and potential problems, clarify what is causing or contributing to the problems, determining risks factors that must be managed, and identifying resources/strengths/areas for health promotion Planning Sets goals that will get the patient to their desired level of wellness Establish priorities, identify and write expected patient outcomes, select evidence based nursing interventions, and communicate the plan of nursing care Implementation Help the patient achieve valued health outcomes meaning to promote health, prevent disease or illness, restore health, and facilitate coping with any altered functioning Carry out the plan, continue data collection, modify plan of care if needed, and document care Evaluation Identify how well the patient has achieved goals specified in plan of care Measure how well the patient has achieved desired outcomes, identify factors contributing to the patient’s success or failure, and modify plan of care if needed Four types of Nursing Assessments: Assessment Type Describe Example Comprehensive Initial Shortly after admission; establishes a complete database for problem identification and care planning; collects data concerning all aspects of health Physical exam upon admission to the hospital or at an appointment with PCP Focused Focuses on a specific problem; may done during initial assessment but routinely part of ongoing; identifies new or overlooked problems Patient who states they are constantly coughing who would require a focused assessment of his or her respiratory status This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com Emergency Identifies life threatening problems; physiologic or psychologic problem occurs A lady who comes into the ER complaining of chest and arm pain Time-lapsed Compare current status to baseline data An older woman who was discharged from the hospital after hip replacement and is having a home health nurse come to her house daily to assess her vital signs/ambulation Describe the difference between a medical assessment and a nursing assessment. Medical assessments require a physician, and it is leads to a diagnosis based on pathological conditions, which the physician understands, defines, and treats. Nursing assessments focus on how the patient responds to the actual or potential health problem such as if the patient has any limitations and can meet their basic needs. Maslow’s Hierarchy of Needs – describe each level Self-Actualization: need to reach full potential; each lower level must be met for this level to be met; continues throughout life; focus on strengths not problems Self Esteem: need to feel good, a sense of pride and accomplishment, and respected/appreciated by those around them; altered when a person’s role changes or when body image changes Love & Belonging: understanding and acceptance in giving and receiving love; feeling of belonging to something such as a group; may lead to depression and isolation if unmet Safety & Security: physical and emotional components; protection from potential/actual harm and trusting others without fear, anxiety, or apprehension Physiologic: includes need for oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest; needs to be met to minimally maintain life; most essential and highest priority Self Act uali zati on Self Esteem Love & Belonging Safety & Security Physiologic This study source was downloaded by 100000796615030 from CourseHero.com on 07-03-2021 03:52:41 GMT -05:00 https://www.coursehero.com/file/43642957/Nursing-Process-Admit-Ticketdocx/ This study resource was shared via CourseHero.com 2. Nursing Diagnosis vs Medical Diagnosis – describe the focus of each Nursing Diagnosis - actual or potential health problems that can be prevented or resolved by independent nursing interventions; provide basis for selecting nursing interventions Medical Diagnosis – problems for which the physician directs the primary treatment Parts of Nursing Diagnosis Statements - label and define each component Problem – describes the health state or health problem Etiology – identifies what is causing the problem which can be physiological, psychological