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*develops over time as nurses begin to link certain patterns or events to specific patient outcomes *the novice may need guidance to perceive links intuitively recognized by the experienced nurse * |
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What does the science of nursing involve? |
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analytical thinking causation key factors possible outcomes (to a situation) |
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What scientific principles is the science of nursing based upon? |
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physiology pathophysiology environmental factors research data |
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speculates, derives, or reasons a specific premise based on information and assumptions obtained from the patient |
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asks if the obtained message or information is clearly understood |
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asks if the information obtained is accurate and without error |
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asks if the information is exact and nonjudgmental |
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asks if all the information connects to the central problem |
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developing the nursing database |
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can establish a baseline for future encounters with the patient as well as serve as a point of comparison should the patient's condition change |
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usually gathered from the pt during the health history interview |
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typically problem oriented and describe human responses that have been validated by the nurse |
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defined as "human responses to health conditions and life processes that may develop in a vulnerable individual, family, or community" they are supported by risk factors that contribute to increased vulnerability |
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wellness nursing diagnoses |
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represent the pt's striving for a higher level of health and wellness. they focus on the strengths of the pt. |
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chronic nursing diagnoses |
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NOT A TYPE OF NURSING DIAGNOSIS! ** |
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Mr. P's "anxiety related to perceived threat of death" |
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the human response amenable to nursing intervention as defined by NANDA (North American Nursing Diagnosis Association) |
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signs, symptoms, and statements made by the pt that validate the existence of the actual or wellness nursing diagnosis |
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possible nursing diagnosis next would come the "related factors," which would be the origin of the pt's health problem |
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according to Maslow, which basic needs take priority over all other issues? |
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indicate the progression towards goal achievement; realistic and measurable pt outcomes are written by the nurse to ensure continuity in pt care |
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time frames in pt outcomes |
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every pt outcome must include a time frame that designates the time by which the pt outcome should be met |
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*the nurse executes the interventions that were devised during the planning phase. *the time frame of the implementation phase varies from pt to pt and from nursing diagnosis to nursing diagnosis. *the nurse simultaneously implements the intervention from multiple nursing diagnoses for a pt at any given time. *it is a dynamic process; the nurse is continually interacting with pt, family, and other health care colleagues, changing the plan of care based on the continuous flow of information |
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the nurse, in conjunction with the pt and family, evaluates the status of the plan of care |
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maps that show the outcome of predetermined pt goals over a period of time; for ex, they state what activity the pt should be capable of performing daily based on the pt's diagnosis-related group (DRG) |
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S--subjective data O--objective data (physical exam) A--analysis of data (nursing diagnosis) P--plan of care I--intervention/implementation E--evaluation R--revision of the plan |
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combines the elements of the nursing process to document the progress of pt care in a standard fashion. nursing care plans serve as means of communicating pt progress with other health care colleagues and ensuring continuity of care among the nursing staff. |
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