Nursing Process
The 5 steps for the nursing process
ADPIE
Assessment
Diagnosis
Planning
Implementation
Evaluation
Course of Infection
Incubation period; vague nonspecific symptoms
Prodromal stage: MOST INFECTIOUS STAGE, interval from onset of nonspecific symptoms to more specific
Full Stage: When pt manifests signs and symptoms specific to type of infection
Convalescence: when acute symptoms of infection dissapear
Components of communication
Sender
receiver
channels
referent
Purpose of client records
communication, recording orders, education, care planning, research, decision analysis, historical documentation, reimburment , LEGAL DOCUMENTATION
Learn models
Listen, Elicit, Acknowledge, Recommend, negotiate
The 2 types of data and their sources
Subjective: what someone says (pt, family, pts chart, healthcare team member)
Objective: What the nurse observes and measures (vital signs, readings, skin color)
Medical Asepsis, Surgical Asepsis
Medical: reduces the number of organsims and prevents their spreads. Practices to confine specific organism to specific area
Surgical: eliminates microorganisms from an area, becomes sterile, destroys all spores
Nontherapuetic techniques
Giving reassurance
rejecting
approving/dissapproving
What is HIPAA
Health information portability and accountability act
nurse has duty to maintain patient confidentialiyu of ALL pt info
factors that impede culturally competent nursing care?
mandating change
disrepect for cultural and family based rituals
disregard for cultural practices while in the health care setting
ignorning modifications needs
2 types of diagnosises and their differences
Medical Diagnosis: identifies a disease process and remains the same as long as the disease presents
Nursing Diagnosis: focuses on unhealthy responses to health and illness. Changes from day to day
The chain of infection
Infectious agent, reservoir, portal of exit, modes of transmission, portal of entry, host
Principles of therapeautic communication
-client is primary focus
-professional attitude sets tone
maintain client confidentiality and nonjudgemental tone
use silence, accepting, giving recognition, offering general leads
Common erros in documentation
-inadequate assessment upon admission to the hospital
-not charting current time
-failing to document when the physician was notifed when clients condiiton has changed
DO NOT ERASE
Factors that faciliate culturally competent nursing care?
including cultural assessment
learning rituals, customs, and practices of major cultural groups
determine native language and degree of english fluency
Parts of Nursing Diagnosis
Risk for: Diagnostic problem, etiology
Active Immunity;native vs artifical , Passive Immunity; native vs artifical
Active: immunity produced by the body, following exposure to antigen
Natural:immunization occurs after exposure to pathogens
Artifical: after administration of vaccine
Passive: acquired without immune system being challenged
Natural: breastmilk from mother
Artifical: hep b
S.O.L.E.R
Active Listening
Sit squarely, facing the client
Observe an open posture
Lean forward toward the client
Etablish eye contact
Relax
ABC's of documenting
Accurate, brief, complete
Cultural Sensitivity
some basic knowledge
constructive attitude
health traditions
Steps for Writing Nursing Diagnosis
1. Gather data
2. Highlight abnormal data
3. CLuster abnoral data
4. Utilize NANDA, identify diagnosis
5. Complete either 2 part or 3 part diagnosis
Types of infection
Local: limited to specific parts of the body. localized swelling and redness, Pain and tenderness, loss of function of body part
Systemic: local can spread to damage other parts of the body. fever, increase in pulse and respiratory rate, maliase and energy dec. largenss of lymph nodes
Client innterviewing process
-introducing phase
-working phase
-closure phase/summary
- establish rapport, listen attentively, gather info, observe, provide closure
- open ended vs closed ended questions
Tool for communcation
SBAR
situation
background
assessment
recommendation