CH. 1-3 Nursing process, interprofessional, health promotion and disease prevention

What is the nursing process?

Outlines all actions taken by the nurse and forms the foundation of our decision making.

Nursing Process (ADPIE)

Not a linear process. Assessment, Diagnosis, Planning, Implementation, Evaluation.

Assesment

Collection of important P.T. information, judge P.T.'s knowledge, abilities, and need for care.

Diagnosis

identifying P.T. strengths and problems requiring care. to develop a priority list of nursing diagnoses for patient.

Planning

Expected outcomes and a plan to reach them based on assessment and diagnosis data. individualize care to meet patient-specific needs

Implementing

Carry out the plan outlined, assist P.T. in achieving the desired outcomes identified. Based on P.T.'s response, educate continually, document care appropriately.

Evaluate

measure how well the patient has achieved the outcomes. decide if interventions were effective continue to modify or terminate care based on info.

Interprofessional Team

Volunteers, Physicians, spiritual counselors, social workers, grief counselors, hospice aids, therapists, nurses, NPs, LPNs, PAs, UAPs, pharmicists, registered dieticians.

Benners Model (Novice) stage I

Begins with the onset of education, little to no clinical experience. task-oriented and focused on learning the rules.

Benners Model (Advanced Beginner) stage ii

A new graduate usually functions at this level. Focus more on the clinical situation and apply more facts. Can distinguish abnormal findings, but cannot readily understand their significance.

Benners Model (Competent) stage iii

Nurses achieve this after 2 to 3 years of nursing practice in the same area. Have gained additional experience and can handle client load.

Benners model (Proficient) stage iv

Able to quickly see the bigger picture, immediately give meaning to the cluster of assessment data. more flexible and fluent within their role and able to adapt to various client situations.

Benners model (expert) stage V

Understand what needs to be achieved and how to do it. Trust in and use their intuition while operating with a deep understanding of a situation. Highly competent skills.

Primary services

Nursing and health promotion, nursing and illness prevention (Activities targeted to minimize risk and development of disease)

Tertiary Services

Refer to long-term rehab services and care for the dying

Five components of caring

Knowing, being with, doing for, enabling and maintaing belief

Knowing

Striving to understand what an event means (illness, a new baby, loss of a loved one)

Being With

Emotionally present for the client (making eye contact, active listening)

Doing For

Doing what clients would do for themselves if they were able (i.e. bathing and feeding)

Enabling

Supporting the client through coping with life changes and unfamiliar events (i.e. hospitalization, birth of a premature infant)

Maintain Belief

Having faith in the client’s ability to get through the change or event and to find fulfillment and meaning (i.e., adapting to a loss of limb or a new colostomy.

Subjective

Data the nurse receives via direct communication with the client, family, or community. (symptoms) i.e. my throat hurts when I swallow.

Objective

Gathered by physical assessment and from lab or diagnostic tests. can be measured or observed by the nurse or other healthcare providers. Can be used to validate subjective data.

Closed question in interview

Those that can be answered with a yes or no. or other short factual answer (directive interview)

Open ended question in interview

Specify a topic to be explored, but phrase it broadly to encourage the patient to elaborate (non-directive interview)

Five rights of delegation

Right task, right circumstance, right person, right direction/communication, right supervision/evaluation.