NS 303 Exam 1 Nursing process, Assessment, Communicationrename
olanjones's version from 2016-05-25 14:27
Nursing Process / Diagnoses
|ADPIE||Assessment, Diagnosis, Planning, Implementation, Evaluation|
|Assess||systematic and continuous process of collecting, organizing, validating and recording data (information) about a client’s health status. Nursing assessment focuses on the client's responses to a health problem.|
|Diagnose||a clinical judgement re individual, family or community responses to actual and potential health problems/life processes. Provides basis for selection of nursing interventions to achieve outcome for which the nurse is accountable.|
|Planning||deliberative, systematic phase of nursing process that involves decision making and problem solving. The nurse refers to the client’s assessment data and diagnostic statements for direction in formulating client goals/outcomes and designing nursing interventions. An intervention is any treatment, based on clinical judgement and knowledge, that a nurse performs to enhance patient outcomes. Intervention comes from the etiology of the diagnosis and is caregiver driven. Outcome statements come from the “problem” of the diagnosis, must be time-measured.|
|Implementation||interventions are implemented but only after first reassessing the need for each intervention.|
|Evaluate||outcomes are used to evaluate the interventions. They are either “met, not met or partially met.”|
|Outcomes origin||“problem” of diagnosis statement.|
|Interventions origin||etiology part of diagnosis statement.|
|Nursing diagnosis||deals with human response to illness, wellness, etc. Clinical judgement about family or community responses to actual and potential health problems or life processes. Provides basis for selection or nursing interventions to achieve outcomes for which the nurse is accountable|
|2 part nursing diagnosis||diagnosis r/t etiology. “Impaired skin integrity related to altered circulation.”|
|3 part nursing diagnosis||diagnosis r/t etiology AMB S/S. “Impaired skin integrity related to altered circulation as manifested by four-inch diameter lesion on left ventral foot.”|
|Order of physical assessment (excluding abdomen)||IPPA: Inspection, Palpation, Percussion, Auscultation|
|Inspect||Visual inspection. Nurse uses naked eye and a lighted instrument to assess moisture, color, and texture of body surfaces. The olfactory (smell) and auditory (hearing) cues are noted as well. Shape, position, color and symmetry of body are noted.|
|Palpation||examination of body using the sense of touch. Effectiveness depends largely on ct relaxation. Pads of fingers used bc their concentration of nerve endings makes them highly sensitive to tactile discrimination. Used to determine: |
-position, size, consistency and mobility of organs or masses
-presence of pain upon pressure
|Light palpation||always precedes deep palpation because deep palpation may dull the sense of touch. Nurse extends the dominant hand’s fingers parallel to the skin surface and presses gently while moving hand in a circle. The skin is slightly depressed. If needed to determine details of a mass, the nurse presses lightly several times rather than holding down the pressure.|
|Deep palpation||done with two hands (bimanually) or one hand. Bimanual – nurse extends the dominant hand as if for light palpation, then places the finger pads of the nondominant hand on the dorsal surface of the distal interphalangeal joint of the middle three fingers of the dominant hand. Top hand applies the pressure. For one handed, one hand is used to feel the mass while the other is used to support the mass or body below. The back of the hand is best suited to test the temperature; the palmar surface is used to test for vibration. |
-The nurses hands should be clean and warm
- Areas of tenderness should be palpated last
-Deep palpation should be done AFTER superficial palpation
|Percussion||The act of striking the body surface to elicit sounds that can be heard or vibration that can be felt. |
-Direct percussions are assessed by the nurse strikes area to be percussed directly with pads of fingers.
-Indirect percussions involve the nurse striking their own finger or hand pressed again the area to be percussed.
-Percussion is used to determine size and shape of internal organs by establishing their borders. It indicates whether tissue is fluid filled, air filled or solid.
|Percussion elicits 5 types of sounds||Flatness, dullness, resonance, hyperresonance, and tympany.|
|Auscultation||process of listening to sounds produced within the body. Direct is the use of an unaided ear. Indirect is the use of a stethoscope. Sounds are described according to their pitch, intensity, duration and quality.|
|Order of Abdominal Assessment||IAPP: Inspect, Auscultate, Percussion then LAST IS PALPATION. Palpation could disturb abdomen, affect results of inspection, auscultation and percussion.|
Therapeutic communication & Standard protocol for skills
|Techniques facilitating communication||-Using silence |
-Providing general leads
-Being specific & tentative
-Using open ended questions
-clarifying time or sequence
-summarizing and planning
|Barriers to communication||-stereotyping |
-giving common advice
|Before skills||- verify orders if skill is dependent or collaborative nursing intervention |
- Gather equipment/supplies and complete necessary charges according to agency policy
- Supplies for all interventions:
+ Armband (or picture) for client identification
+ consent form if required by policy
+ clean gloves for mucous membrane contact, nonintact skin, or moist body substances.
- Perform hand hygiene for at least 10-15 seconds before each client contact.
- Identify client by checking identification bracelet and having client state name and DOB
- Introduce yourself to client including your Name, Title and Role.
- Explain what you plan to do
- Identify teaching needs and describe what the client can expect in simple terms.
- Assess client to determine if the intervention is still appropriate
- Adjust the bed to appropriate height and lower rail on side nearest to you.
- Provide adequate lighting for procedure
- Provide privacy for client, position and drape as needed.
|During Skill||-Promote client independence and involvement|
-Assess the client tolerance. Be alert for signs of discomfort and fatigue
|After Skill||-Assist client to position of comfort, and organize needed toiletry and personal items within reach |
-Be certain client has way to call for help and knows how to use it.
-Raise the appropriate number of side rails and lower bed to lowest position
-Dispose of used supplies and equipment
-Remove and dispose of gloves, perform hand hygiene
-Document and report client’s response and expected or unexpected outcomes.
|OLDCAARTS - a symptom analysis for problems, only used if a problem exists||O - Onset|
L - Location
D - Duration
C - Characteristics
A - Aggravating Factors
A - Alleviating factors
R - Related symptoms
T - Treatments (self-treatments tried before seeking care)
S - Severity of symptom (size, number, extent, pain scale, interruptions of ADLs)