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93 Cards in this Set
- Front
- Back
Nursing Process
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Assess - gather info about clients conditon
Diagnose - identify the clients problems Plan - set goals, desired outcomes and identify appropriate nusing actions Implement - perform nursing actions identified in the plan Evaluate - determine if goals are met and outcome is achieved |
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Banner
Novice to Expert |
Novice - beginning nursing student
Advanced beginner - some level of experience competent - some clinical position 2-3 years Proficient - greater than 2-3 years experience Expert - Nurse with diverese experience who has intuitive grasp of existing or potential clinical problem |
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Historical Perspective
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Prostitutes and Nuns were the only 2 types of nurses originally because they served intmately...Stereoptypes - Always a woman, Nurse Jackie, Nurse Rachet
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Florence Nightengale
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Lady with the Lamp
Crimean war 1835 Sanitation and nutrition were her contribution to health care also wrote "notes on nursing" |
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NLN
National League for Nursing (core values) |
Caring
Integrity Diversity Excellence |
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ANA
American Nurses Association Standards of Practice |
Nursing Practice
Assessment Diagnosis Outcome/Identification Planning Implementation Evaluation |
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Societal Influences on Nursing
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Demographic Changes
-population shift - multicultural -rural areas to uban areas -life span -higher incidence of long-term, chronic illness Womens' Health care - demographics, human rights movement, medically underserved, threat of bioterrorism |
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Nursing As a Profession
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Art and Science
Art - laying on of the hands Science - scientific basis rational/reason why nurses do what they do |
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Scope of Practice
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Standards of things nurses can do
legally standards of care standards of professional perfection code of ethics |
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ANA - standards of professional performance
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Professional Performance
Quality of Practice Education Professinal Practice Evaluation Collegiality Colaboration Ethics Reserch research Utilization Leadership |
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Nurse Practice Act
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-dictated by each individual state
-what a licensed nurse can do -KY board of nursing-nurse practice act You can loose your license if you do anyting outside of the states nurse practice act you are performing nursing duties in |
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Nursing Educaton
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ANA - BSN
Other=diploma nurses, ADN, RN, LPN (came along due to shortage of nurses) -course work must be completed and NCLEX taken/passed |
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NCLEX
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Standardized exam across the US - state-to-state...assures that all nurses have the minimum knowledge required for nursing
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Roles of Nursing
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Caregiver- help regain health
Advocate- protects clients human and legal rights Educator- explains concepts and facts Communicator- helps you know your clients needs and wants met Manager- collaborative care to provide Must speak three langauages: Nursing, Doctor, and Patient |
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Health Service Pyramid
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Tertiatry health care
secondary health care primary health care clinical preventative services population-based health care service |
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Examples of Health Care Services
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Primary Care
Preventive Care Secondary Acute Care Tertiary Care Restorative Care Continued Care |
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Primary Care
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Health Promotion-health for all
Prenatal Care Well-baby care Nutrition counsling Family planning Excercise classes Education/Communication |
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Preventive Care
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Blood Pressure and Cancer Screening
Immunizations Poison control information Mental Health Counseling and Crisis prevention community legislation (seatbelts, airbags, bike helmets) |
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Secondary Acute Care
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Emergency Care
Acute medical sergical care Radiological procedures |
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Tertiary Care
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Intensive Care
Subacute Care |
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Restorative Care
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Cardio and pulmonary rehab sports medicine
spinal cord injruy programs home care |
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Globilization of Heath Care
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Because of the internet clients are more educated about helth care- physicians and helath care providers must make health care more accessible
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Continuing Care
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Assisted Living
Psychiatric and Older adult day care |
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Community Based Heath Care
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-modle of care that reaches everyone in the community
-focus is on primary, rather than institutional or acute care -provides knowledge about health and health promotion |
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Community Based Nursing
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Care takes place oin community settings - home or clinics
-to provide healthcare close to where family lives |
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Vulnerable Populations
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Clients more likely to develop health problems as a result of excess risks, who have limits to helthcare serveces, or who are dependent on others for care
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Community Assessment
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Structure
Population Social System |
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Community Assessment Structure
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-name of comm. or neigh.
-geographical boundries -Emergency services -water and sanitation -housing -economic status |
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Community Assessment Population
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-age distribution
-sex distribution -growth trends -density -education level -ethnic groups -religioius groups |
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Community Assessment
Social System |
-education system
-government -communication system -welfare system -volunteer programs -health system |
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Changing Clients Heath (Project)
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Becoming familiar with a community practice setting. Will help you learn and identify the unique needs of individual clients
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Components of a Theory
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Theory= set of concepts, definitions, and assumptions or propositions to explain a phenomenon
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Types of Theries
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Grand Theories
Middle Range Theories Descriptive Theories Prescriptive Theories |
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Grand Theories
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broad is scope, complex, and therefore require further specificaiton through research
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Middle-Range Theories
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More limited in scope and less abstract
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Descriptive Theories
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First level of theory development
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Prescriptive Theories
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Address nursing interventions and predict outcome of nursing action
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Nursing Theories
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an interpretation of some portion of nursing communicated for the purpose of describing, explaining, predicting, and/or prescribing nursing care
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Maslow's Hierarchy of Needs
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self actualization needs
esteem needs belongingness and love needs safety needs biological/physiological needs |
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Maslow's Hierarchy of Needs
Self-Actualization |
self fulfillment and realization of one's potential
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Maslow's Hierarchy of Needs
Esteem Needs |
Fullfillment of approval of others - recognition
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Maslow's Hierarchy of Needs
Belongingness and Love Needs |
fullfillment of acceptance of others to belong
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Maslow's Hierarchy of Needs
Safety Needs |
fullfillment of security and safety
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Maslow's Hierarchy of Needs
Biological Needs |
fullfillment of basic needs ie, water, food, shelter.
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Erickson's Develpmental Stages
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Hope
Will Purpose comptence fidelity love care wisdom |
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Erickson's Develpmental Stages
Hope |
Trust vs. Mistrust (Birth - 12/18 mos)
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Erickson's Develpmental Stages
Will |
Autonomy vs Shame and Doubt (toddlers 18 mos - 3 yrs)
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Erickson's Develpmental Stages
Purpose |
Initiative vs Guilt (preschool - 3-6 yrs)
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Erickson's Develpmental Stages
Competence |
Industry vs. Inferiority (Child 6-12 yrs)
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Erickson's Develpmental Stages
Fidelity |
Infidelity Vs. Role Confusion (adolecents 12-18 yrs)
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Erickson's Develpmental Stages
Love |
Intimacy vs. Isolation (19 yrs-40 yrs)
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Erickson's Develpmental Stages
Care |
Generativity vs. Stagnation (40 yrs - 65 yrs)
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Erickson's Develpmental Stages
Wisdom |
Egointegrity vs. Despair (65 yrs and up)
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Why Evidence Based Practice?
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This gives you rationale/ reason for what you are doing
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Evidence Based Practice
Rationale |
is a problem solving approach to clinical practice that intergrates conscientious use of best evidence in combination with a clinician's expertise and client preference nad values in decision making about client care
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Case for Evidence
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because clients are more medically knwoledgeable EBP is important to avoid health care approches that do not work. EBP is a guide for nurses to structure how to make accurate, timely, and appropriate clinical decisions.
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Steps for Evidence Based Practice
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Ask a question
collect the most relevent and best evidence critically appraise the evidence you gather intergrate all evidences w/ one's clinical expertise and client preference and values in makind a practice decsion or change Evaluate the practice decision ofr change. |
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Informed Consent
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Inform patient of what is going to happen - must ask if you ccan study them - develp theory - surgery- signing concent proves/verifys Dr. has come and told them everything about surgery
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Data Collection
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General
Observation overvies look for cues (client crying) Make inference (interpretation of cue) Assessment cues - specific Ask more focused questions about specific cues |
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Objective Data
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Observations or measurements of a clients health status
BP Temp CBC |
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Subjective Data
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What the patient tells you
pain dizzyness |
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Methods for Data Collection
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Interview and Nursing Health
History - physical exam results of lab work all lead to client assessment database |
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Phases of the Nurse-Client Relationship
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Orientation Phase-indtroduction
Working Phase-gathering info Termnination Phase-ending interview Nonverbal-client directed gaze-affirmative head nods - smiling- forward leaning- touch |
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Culture Related to Asssessment
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Learning and understanding cultural differences is important to gain an accurate assessment for clients with different cultural beliefs
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Nursing Health History
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Gathering information about client
biographical infor, reason for seeking care, client expectations, present illness or health concerns, health history, family history, environmental history, psychosocial history, spirtual health, review of systems documentation of history finding |
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Medical Diagnosis
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The identification of a disease condition based on specific evaluation of physical signs, symptoms, the clients medical history, and the results of diagnotic tests and procedures
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Nursign Diagnosis
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Clinical judgement about individual, fmaily, or community responses to actual or potential health problems or life processes
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History of Nursing Diagnosis
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First introduced in 1950
emphasized nurses independent practice compared to dependent practive driven by DR. Defined client centered problems classifications for nursing diagnosis NANDA in 1982 |
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Safety
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What is going to kill them first?
Prioritize ABCs - Airway, Breathing and Circulation. |
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NANDA
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to develp, refine, and promote a taxonomy of nursing diagnostic terminology of general use for professional nurses
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Formulation of a Nursing Diagnosis
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NANDA supports this diagnostic judgement also supports assessment data
Risk diagnosis - posible will develop in a vulnerable individual Health promotion- to increase well being Wellness nursing - readiness for enhancement |
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Components of a Nursing Diagnosis
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Diagnostic Label
Related Factors Defintion Risk factors Support of Diagnstic statment |
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Components of a Nursing Diagnosis Diagnostic Label
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name of nursing diagnosis (NANDA)
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Components of a Nursing Diagnosis
Related Factors |
condition or cause of disease identifed from assessment
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Components of a Nursing Diagnosis
Defenition |
NANDA approves and defines each diagnosis
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Components of a Nursing Diagnosis
Risk Factors |
Elements that increase the vulnerbility of a client
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Components of a Nursing Diagnosis
Support of the Diagnostic Statment |
Nursing assessment data needs to support the diagnostic lables - as evidenced by and ambulates
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Priorities in Practice
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Can be affected by health care environment - interuptions, available resources, policy and procedures, supply access.
Cognitive shifts attention from one client to another during conduct of the nursing process |
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Goals of Care
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Client centered goals sould be specific and measureable behavior or response that reflects clients highest level of wellness and independence in function "Client will..."
short term and long term goals |
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Guidelines for Writing a Goal
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Client Centerd, Singular gola or outcome, observable, measureable, time-limited, mutual factors, realistic
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Types of Intervention
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Indenpendent nursing interventions, dependent nursing interventions, collaborative interventions...when choosing consider...characaristic of nursing diagnosis, goals expected, evidence base, fasability, acceptability to client, your compencey
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Examples of Interventions
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Cerate a calm and supportive environment
provide a safe and clean environment adujst room temp to that most comfortable for individual avoid unnecessary exposure, drafts, over heating, or chilling etc. |
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consulting other Healthcare Providers
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consultation is the process of seekign the expertise of a specialist. You should seek help when you are unable to solve a problem. Identify problem and direct problem to correct proessional provide relevent info.
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Standing Orders
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Preprinted document containing orders for the conduct of routine therapies, monitoring and/or diagnostic procedures...they are provided by licensed prescribing physicians or helth care providers in charge of care at thime of implimentation...common in critical care...they give nurse ability/protection to interviene appropriately in clients best interest
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Implementation Process
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Reassessin the client reviewing and revisiting the existing health care plan...organizing resources nad care delivery equipment- personnel, environment, client
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Reassessing the Client
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a continuing process which occurs each time you interact with a client...new inforation gained from assessment should modify the careplan
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Reviewing and Revising Plan of Care
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After reassessment
revise data in the assessement revise the nursing diagnosis revise specific interventions determine the method of evaluation for determining if achieved outcome |
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Direct Care
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ADL
Physical Care Techinques Life Saveing Measures Counseling Teaching Controlling for Adverse Reactions Preventivie Measures |
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Indirect Care
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comminicating nusing interventions
documentation, delegation of care, medical order transcription, infection control, environmental safesy management, computer data entry, telephone consults, change of shifts, collecting specimens, transporting patients to procedural areas |
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Communiciating Nursing Interventions
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Will be comminicated in a written and/or oral format
written are nursing careplans will communicate |
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Interdisciplinary Care Plans
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Plans representing the contributions of all disciplines caring for a client
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Delegating
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An RN delegates components of care but not the nursing process itself
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Evaluation
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Ongoing process whereever you have contact with a client
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