NURSING PROCESS
What is nursing process?
Decision-making framework used by all nurses to determine the needs of their pts and to decide how to care for them.
The use of concept maps to plan care
A way of making connections between the steps of the nursing process and determining interventions to be performed.
What is documentation?
The act of recording pertinent medical information in a pts medical record.
What is Active listening
It uses all the senses to interpret verbal and nonverbal messages. Nurses pay attention to what the speaker is saying and also what the speaker is not saying.
What is direct pt care
Interacting with the pt directly to implement interventions.
Steps of the nursing process
Assessment, Diagnosis, Planning, Implementation, Evaluation
Expected outcomes
statements of measurable action for the pt within a specific time frame
What is confidentiality of pt records?
Maintaining the privacy by not sharing pt records with third parties.
DESC communication
D is for describe. E is for explain. S is for state. C is for consequences
Information obtained from pt family, friends, and pt chart
The 3 components to assessment
Interviewing, Performing a focused body system assessment, and Reviewing the lab and diagnostic test
Types of nursing care plans
Computerized care plans, Standardized care plans, Multidisciplinary care plans, Critical pathways, and Student care plans.
Purposes for written documentation.
to communicate pt data, to provide a permanent record of medical diagnosis, nursing diagnosis,etc. To serve as a record of accountability, to serve as a legal record.
Types of communication
Verbal communication and Nonverbal communication
What is SOAPIER charting?
Used in progress notes and the nurses notes. Includes subjective, objective, assessment data, a plan, an intervention, an evaluation, and as needed a revision.
Nursing diagnosis
A statement for a problem that a pt is experiencing as a result of the medical diagnosis.
nursing diagnosis is not the same as physician diagnosis.
How is NANDA-I nursing diagnosis listed?
Standardized format. Arranged with the primary topic first, followed by modifiers.
Source- oriented and problem-oriented records.
Source-oriented records are organized according to the source or type of data.
Problem-oriented records are organized around the pts individual problems.
What influences communication
Personal space, body position, language, culture, attitude, and emotion
What is Denotative meaning?
The literal meaning, no interpretation needed.
The use of Maslow's to prioritize nursing diagnosis.
It is used for addressing the most basic needs first. Such as airway and breathing
What does THREE-PART nursing diagnosis contain?
A label diagnosis, etiology and defining characteristics exhibited by the pt.
The importance of EHRs
It provides a way to pool collected data and information, provides evidence based practice, and helps identify needs for staff continuing education.
Styles of communication
Passive or avoidant, Aggressive, and Assertive behavior.
What is Therapeutic communication?
Pt-centered communication in which the goal is to promote a greater understanding of the pts needs, concerns, and feelings.