What is the difference between nursing and medical diagnosis quizlet?
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purpose of nursing process Show to diagnose and treat human responses to actual or potential health problems what information does a nurse collect during an assessment. needs for medication nursing diagnosis statements Provides a precise definition of a patient's problem that gives nurses and other members of the health care team a common language for understanding patients' needs Allows nurses to communicate what they do among themselves and with other health care professionals and the public Distinguishes the nurse's role from that of the physician or other health care provider Helps nurses focus on the scope of nursing practice ... ... ... ... ... ... Maslow's hierarchy of needs is used to prioritize patient needs Foundation for the clinical practice of nursing
Assessment ... ... What is the foundation for the clinical practice of nursing? Nursing process holistic care care that promotes physical, emotional, social, intellectual, and spiritual well-being first step in nursing process Assessment: Assessment is an ongoing process that starts with admission and continues until the patient is discharged from care Nursing Diagnosis is.. A clinical judgment about individual, family, or community responses to actual or potential health problems/life processes (NANDA-I)
method used to help with nursing diagnosis Gordon's Functional Health Patterns Model Five Types of Nursing Diagnosis 1.Actual: based on human responses and supported by defining characteristics 2.Risk/high-risk: patient may be more susceptible to a particular problem 3.Possible: suspected problems requiring additional data 4.Wellness: clinical judgment about a transition from one level to a higher level 5.Syndrome: cluster signs and symptoms to predict certain circumstances or events A clinical judgment that a person is more susceptible to a particular problem than others in the same situation is defined as which type of nursing diagnosis? Risk/high risk Collaborative Problems Different from nursing diagnoses when the intervention used is to prevent or treat a problem and is worded with potential complication in the diagnosis Collaborative Problems are based on Evidence-based practice uses research to impact nursing practice changes; the interventions used in the research findings can be implemented into care plans medical diagnosis vs nursing diagnosis Medical diagnosis is a diagnosis of a disease or disorder that impairs normal physiologic function Nursing Diagnosis vs Medical Diagnosis Nursing diagnosis refers to the patient's ability to function in ADLs; it identifies the patient's response to the illness How does a nursing diagnosis differ from a medical diagnosis? A nursing diagnosis evaluates a patient's response to actual or potential health problems. Phases of Planning (4) Setting priorities Developing measurable goal/outcome statements Formulating nursing interventions Formulating anticipated therapeutic outcomes Phases of Planning -Setting priorities: identify problems and prioritize -Developing measurable goal statements: write short- and long-term goals for the patient -Formulating nursing interventions and anticipated outcomes: The Nursing Outcome Classification (NOC) system provides standardized outcomes and specific indicators to assess the effectiveness of nursing interventions The Nursing Interventions Classification (NIC) system provides scientifically validated nursing interventions to treat a diagnosis. Goals of Evidence Based Practice improve patient outcomes by implementing best practices evolved from scientific studies Uses best care practices to improve patient outcomes Nursing Intervention or Implementation Actual process of carrying out the established plan of care Nursing actions are suggested Dependent actions: performed by a nurse based on health care provider's orders Interdependent actions: implemented with the cooperation of a team Independent actions: provided by nurse by virtue of education and license Example of a dependent action: monitoring a patient's heart rate and rhythm while the patient is receiving antidysrhythmic therapy. Example of an independent action: listening to a patient's lung sounds after a respiratory treatment and monitoring laboratory values.
Nursing interventions meeting the physical needs of the patient, providing for patient safety, monitoring for potential complications, assessing and evaluating to identify changes in the patient's needs Therapeutic outcomes are developed to evaluate the effectiveness of the care given All care is evaluated against Nursing diagnoses (goal statements) Evaluation process involves patient, family, and significant others who provide feedback and help determine goals dependent nursing actions Performed by the nurse on the basis of the healthcare providers
orders Interdependent nursing actions nurse performs actions in collaboration with another health care team member independent nursing actions Not prescribed by a healthcare provider, but nurse can provide by virtue of the education and licensure held. example of independent nursing action? Verifies the correct route of medication administration Three reasons for obtaining a drug history To evaluate need for medication To obtain current and past use of over-the-counter medication To identify problems related to drug therapy Primary patient information may be unreliable or patients may be poor historians. Assessment relies on Primary source: produced by patient Secondary sources: relatives, significant others, medical records, lab reports Tertiary sources: literature to provide background information, diagnostic tests, diet Which piece of information obtained during a patient assessment is a subjective finding? Patient states, "I have pain in my abdomen." Nursing diagnoses often can be formulated based on the patient's drug therapy Review the drug monographs to identify problems related to medication therapy planning phase Identify the therapeutic intent and common and serious adverse effects Check that scheduling of administration of medicine is based on the provider's orders Nurses prepare the prescribed medications using procedures to ensure patient safety Select correct supplies (syringes, etc.) Verify all aspects before preparation Collect appropriate data to serve as baseline for later assessments Administer medication by correct route Document all aspects of administration Implement actions to minimize expected side effects Educate patient as appropriate Evaluation procedure for determining therapeutic outcomes of drug therapy include Assessing patient
responses to medications Cognitive Domain Involves learning and storing knowledge Psychomotor Domain Involves learning and storing knowledge physical skills Learning Domains cognitive, affective, psychomotor Affective domain Involves feelings, needs, values, and opinion The nurse is preparing to teach a postsurgical patient who has a new colostomy about proper colostomy care. The patient says, "Just show me how to do it; let me try, and I'll learn what to do." Which domain of learning is indicated by this statement? Psychomotor Focus the learning Repeat information to help master concepts Learning Styles Fit teaching techniques to learner's style Organization of material to be learned Use objectives and an outline for teaching Allow time to practice and ask questions Review what has been taught
Motivation Provide positive feedback when teaching Determine through patient outcomes when more teaching is needed Readiness to Learn Ensure patient's basic needs are met first Depends on what patient already knows and motivation to learn Make the content relevant Learning pace Depends on learning style Depends on age of patient Psychosocial adaptation to illness During grieving, patient will not be able to learn Adult Education Adults need to first understand why they must learn something Assess what the adult already knows and what information is desired Make the content relevant to that individual Older Adults Assess vision, hearing, short- and long-term memory, and fine and gross motor skills Assess concerns regarding cost Older adults may consider the balance between proposed treatment and quality of life Slow pace of the presentation, allow time to process new information things to remember for an older adult A new diagnosis or treatment may seem overwhelming, impairing learning. Slow the pace of presentation. Limit duration of each session. Consider effect of lighting, glare, and noise on learning. Speak clearly without shouting. fear and anxiety Provide information in small increments Ability to focus on details is reduced Anticipate
inopportune times to initiate teaching Praise efforts and positive aspects Consider patient's what Consider patient's educational level and ability to read and understand written material. Consider patient's preference for written material or audiovisual. The nurse may need to "translate" medical terms into terms patient can understand. Principles of Learning Space the content, staggering the amount of material presented in one session Repetition enhances learning Consider the patient's educational level and literacy People tend to remember what is taught first Multiple shorter sessions less likely to overwhelm the learner. Culture and ethnic diversity Ethnocentrism—recognize its impact Work with an interpreter Internet—impact on health information adherence The degree to which the patient is likely to follow teaching relates to how much value the patient attaches to it patients beliefs Perform a cultural assessment to determine factors that relate to the beliefs of the patient. Understand that each nurse brings beliefs about health practices that affect relationships with patients. Variables influencing the patient's response to the therapeutic regimen Perceptions of the benefits, attitude toward health care providers, effect on own lifestyle, family situations, understanding of the illness Cost, family support, presence or loss of control, side effects, convenience, physical ability to shop, open containers Encourage Adherence Patients have right to make their own life choices Positive reinforcement helps patients succeed Response and compliance depend on numerous variables Response and compliance depend on numerous variables Comprehension and understanding Multiple physicians Family support Control over disease Side effects Expectations and fears Physical limitations Ethnography Used to observe how patients follow health care regimen at home Case Management Adherence Guidelines include the patient's motivation and knowledge level of prescribed medications. It also assesses social support systems. The nurse is supposed to perform postoperative teaching for a patient who is scheduled to be discharged the next day. The patient appears fatigued, in pain, and irritable. The nurse knows that there will be little time for teaching on the day of discharge. What is the nurse's best course of action? Determine the patient's need for analgesia and rest, and return to perform the teaching after the patient feels better. An older adult patient is being prepared for discharge after experiencing a stroke with some residual damage. The patient and family are scheduled to receive a large amount of information from the nurse regarding proper care and safety at home. What is the nurse's best course of action? Break the teaching content down into manageable sections and present them individually in the days before discharge. The nurse is preparing a patient for discharge after a surgical procedure. Which method is best for teaching the patient about his or her prescribed drugs? Verbal explanations along with drug summary sheets The nurse who is new to a large urban hospital has found that many of the hospitalized patients are of different cultural groups in the area. Which approach is best for the nurse to take in caring for these patients? Develop a plan of care that is individualized to each patient's needs. Which step of the nursing process is used when the nurse identifies the therapeutic intent of a prescribed medication? Planning Which type of nursing action occurs when the nurse administers a medication to a patient? Dependent Which is a measurable goal statement for a patient taking insulin injections? The patient will be able to self-administer insulin injections 2 weeks after initial training This goal is patient focused and includes measurable behavioral changes and a time frame for it to be accomplished Which assessment finding is considered primary, objective information? The patient states that his temperature has been 98.8°F. Which information is considered objective data? Laboratory results Which correctly identifies the NMDS classification system? Nursing Minimum Data Set Which phase of the five-step nursing process is diagnosis? Second Which correctly distinguishes a nursing diagnosis from a medical diagnosis? Nursing diagnosis refers to the patient's ability to function in activities of daily living. Which statement about a critical care pathway is true? It is a standardized care plan derived from "best practice" patterns. The nurse is preparing to administer morning medications. Which action(s) does the nurse implement to identify the patient before administering medications? Checks the patient's identification band Asks the patient his or her name and birth date Which is a priority outcome for patient teaching about prescribed drug therapy? The patient will take the medication as prescribed, not changing or discontinuing it without contacting the healthcare provider Which statement describes a characteristic of Case Management Adherence Guidelines version 1 (CMAG 1)? The caregiver and patient have ownership of the goals to be achieved. Which teaching method is the most effective when teaching patients about medications? Designing a teaching method and pace for each patient Which portion of the learning process is involved in the cognitive domain? Thinking Which scenario represents the best time for the nurse to initiate patient teaching? When the patient spontaneously starts asking questions The nurse is teaching a patient who has been diagnosed with hypertension. Which statement by the patient indicates the need for further education? "A sedentary lifestyle is the best way to live." Which stage of grief represents when the patient is most willing to learn Resolution Which teaching strategy does the nurse use when teaching an elderly patient? Incorporating time for practicing Which statement is true about culture and ethnic diversity? Unless an assessment of psychosocial needs is performed on the patient, the true meaning of an illness may never be uncovered The nurse is developing a teaching plan for a patient's prescribed medication. Which action(s) should the nurse implement to make the plan more effective? Assess the patient's readiness to learn. Request patient feedback of the information being taught. Incorporate multiple practice sessions The nurse is preparing a client prescribed medication in order to ensure client safety the nurse should perform which interventions prior to administration Educate client regarding medication prescribed check two identifiers What do the classification systems NIC and an NOC provide Standardized language for reporting and analyzing nursing care delivery Which outcome statement identified by the nurses writing correctly Within the next four hours client will report pain level less than 3 out of 10 What is an example of ethnocentrism A 36-year-old Asian prefers to take herbs instead of oral medication What is the purpose of the nursing assessment Determining the clients mental status Client expresses concern about feeling different from his peers affective What is the difference between nursing and medical diagnosis?What is the difference between a medical diagnosis and a nursing diagnosis? A medical diagnosis deals with disease or medical condition. A nursing diagnosis deals with human response to actual or potential health problems and life processes.
What is nursing diagnosis in simple words?“A nursing diagnosis is a clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group or community.
What is the meaning of medical diagnosis?(DY-ug-NOH-sis) The process of identifying a disease, condition, or injury from its signs and symptoms. A health history, physical exam, and tests, such as blood tests, imaging tests, and biopsies, may be used to help make a diagnosis.
Which is the primary fundamental difference between nursing and medicine quizlet?Terms in this set (46) What is the difference between nursing and medicine? Nursing is care for the whole patient. Medicine is diagnosis and treatment of disease.
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