NUR 306 Study Guide - Fall 2018, Comprehensive Midterm Notes -
NUR 306
MIDTERM EXAM
STUDY GUIDE
Fall 2018
The Nursing Process
• Set a goal
• Develop an action plan
• Implement the plan
• Evaluate the outcome
• Broad systematic framework
• Provides methodical base
• Problem-solving approach addresses human response, needs of patient, family, and community
• ADPIE
o Assessment
▪ Gathering subjective and objective data
▪ Instrumental in devising a care plan
▪ Key points and relevant pieces of information are clustered together
▪ Preliminary problem list is formulated
▪ Assessment phase continues throughout entire patient encounter
o Diagnosis
▪ Based on real or potential health problems or human responses to health problems
▪ Based on assessment data and patient problem list
▪ Sets stage for remainder of care plan
o Planning
▪ Deise the est ourse of atio to address patiet’s diagoses
▪ Nurse and patient select goals for each diagnosis
▪ Set short-term goals (STG) and long-term goals (LTG)
▪ Be realistic
▪ Work ith patiet’s goals, eooi eas, opetig resposiilities, ad faily
structure and dynamics
o Implementation
▪ Can be completed by patient, family, or health care team
▪ Clearly relate to nursing diagnosis and planned goals
▪ Individualized for each patient
▪ Modified as changes occur
▪ Support positive outcomes
o Evaluation
▪ Continuing process to determine if goals have been attained
▪ Based o patiet’s condition
▪ Goals are realistic or appropriate
▪ Ongoing process
▪ Confirms that nursing care is relevant
Types of Data
• Subjective—Symptoms
o What patient tells you
o History
o Chief complaint
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o Review of systems
o OLD CART
▪ Onset
• When did the sign or symptom begin?
▪ Location
• Where is the sign or symptom located?
▪ Duration
• How long has the sign or symptom been going on?
▪ Characteristic symptoms
• What the symptom feels like; how it is described; what is the severity?
▪ Associated manifestations
• What else is happening when the patient experiences these sign(s) or
symptom(s)?
▪ Relieving factors
• Anything the patient has tried to relive the symptom
▪ Treatment
• Any interventions the patient has previously tried
• Objective—Signs
o What you see
o Physical examination
o Laboratory reports
o Radiologic findings
Clinical Reasoning
• Assessment & Diagnosis
o 3 types of reasoning for clinical problem solving:
▪ Pattern recognition
▪ Development of schemas
▪ Application of relevant basic and clinical science
• Steps
o Identify abnormal or positive findings
▪ Make a list
▪ Patiet’s syptos
▪ Observed signs
▪ Identify the positive responses
o Cluster the findings
▪ Group complaints with area in body
▪ Include information on stress level
▪ Be specific
▪ Localize symptoms and signs, if possible
▪ Include any psychosocial issues
o Interpret the findings
▪ Patient problems can stem from different causes:
• Disease processes
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Document Summary
Implement the plan: set a goal, develop an action plan, evaluate the outcome, broad systematic framework, provides methodical base, problem-solving approach addresses human response, needs of patient, family, and community, adpie, assessment. Implementation: can be completed by patient, family, or health care team, clearly relate to nursing diagnosis and planned goals, modified as changes occur, support positive outcomes. Individualized for each patient: evaluation, continuing process to determine if goals have been attained, based o(cid:374) patie(cid:374)t"s condition, goals are realistic or appropriate, ongoing process, confirms that nursing care is relevant. Clinical reasoning: assessment & diagnosis, 3 types of reasoning for clinical problem solving, pattern recognition, development of schemas, application of relevant basic and clinical science, steps. Identify abnormal or positive findings: make a list, patie(cid:374)t"s sy(cid:373)pto(cid:373)s, observed signs. Identify the positive responses: cluster the findings, group complaints with area in body. Include information on stress level: be specific, localize symptoms and signs, if possible.
