#2-Summary and Study Guide Foundations of Nursing -Assignment Summary Assignment
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#2-Summary and Study Guide Foundations of Nursing -Assignment Summary Assignment #2 Answer the following questions using a separate sheet of paper Chapter 5- Nursing Process 1. What is the Nursing Process? 2. List the stages/phases of the nursing process and give a brief description of each. 3. List the types of data and give an example of each 4. List the sources of data and give an example of each 5. What is data clustering? 6.Differntiate Nursing Diagnosis from Medical Diagnosis 7. Describe the types of Nursing Diagnosis. Chapter 3 Documentation 8. Describe four types of Charting/Documentation 9. Explain nursing responsibilities as it relates to documentation. Chapter 6 Cultural and Ethnic Consideration 10. Explain and give examples of how the nurse can include the patient's culture when providing care.Explanation / Answer
1.Nursing process is an orderly,systematic manner of determining the clients problems,making plans to solve them,initiating the plan or assigning others to implement it and evaluating the extent to which the plan was effective in resolving the problems identified.
2.The nursing process provide a scientific framework for the delivery of professional nursing care.It consists of five steps They are Assessment,Nursing Diagnosis,Nursing goal,Implementation,Evaluation.
Nursing Assessment-information is gathered to establish a database for best possible care of the patient.It is deliberate and systematic collection of bio-psychosocial information or data is done to determine the current and past health and functional status and to evaluate past and present coping patterns
Nursing diagnosis are defined as clinical judgements about individual,family or community responses to actual and potential health problems.It is used to describe an individual patient condition,to prescribe nursing interventions and to delineate the parameters for developing outcome criteria
Planning phase consist of the total planning of the patients overall treatment to achieve quality outcomes in a safe,effective and timely manner.Nursing interventions with rationales are selected in the planning phase bsed on the clients identified risk factors and defining characteritics.
Implementation-In the implementation phase nurse sets interventions prescribed in the planning phase.
Evaluation-it is the process of determining the value of an intervention.Nurses determine the effectiveness of intervention s with particular patients.Nurses evaluate selected interventions by judging the patients progress towards the outcome setdown in the nursing care plan.
3.Two types of data are Subjective data and Objective data.Subjective means what the patient tells you.Eg I am itching.
Objective data-detectable by an observer or can be tested.Eg Temperature
4 primary sources and secondary sources
primary source of data is obtained from client
secondary source of data is obtained from all other sources than client.
5 Data clustering is the process of collecting related information from a patients health history,physical examination and lab tests in the process of making a diagnosis.
6 A nursing diagnosis deals with actual or potential health problems and life process whereas medical diagnosis deals with disease or medical condition.Nursing diagnosis direct nursing interventions to obtain patient specific oucomes.Medical diagnosis focus on medical condition and the diagnosis of a doctor mainly focus on the illness itself.Nursing diagnosis is based upon the response of the patient to the medical condition.
7.Three types of Nursing are Actual Nursing Diagnosis,Risk diagnosis,Health promotion Diagnosisand Syndrome Diagnosis.Actual diagnosis is aclinical judgement based on responses to health conditions that exist in an individual or community.Risk diagnosis is based on human responses to health conditions that may develop in a vulnerable community.Health promotion diagnosis is a clinical judgement about a persons or communitys motivation and desire to increase well being.Syndrome diagnosis is a clinical judgement which describes specific cluster of nursing diagnosis which occur together and addressed using same interventions .
8 Narrative charting-it is the traditional method of charting.it is written in paragraphs that describe client status,intervention and treatments.it is the ost flexible dcocumentation.
Source oriented charting-it is the narrative recording of separate documents by each member of the healh team.the main defect is the time consuming communication .
Problem oriented medical record-it is a logical format and fovuses on clients problem.Each problem must have a complete note every 24 hours if unresolved.
Focus charting-it uses a column format to chart Data ,Action and ResponseThe data information corresponds to assessment in the nursing process.
9Documentation is legally required by acrediting agencies,state liscening laws and state nurse and medical practice acts.Document client and family teaching ,what was taught,evaluation of understanding and who was present during the teaching.Use a black coloured pen for narrative documentation.Provide objective,factual and complete documentation.Document care,medications and treatment as soon as possible after completion.sign and title each entry.Do not leave blank spaces pon entry.Follow agency policies when an error is made.
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