1.1 The Nursing Process Flashcards
What is the Nursing Process
Assessment, Diagnosis, Planning, Implementation, Evaluation
Assessment
Collecting and Validating and Communicating Data
Subjective Data - Unmeasurable data provided by patient (dizziness, anxiety)
Objective Data - Measurable and observable data such as elevated temperature, skin moisture and vomiting.
Diagnosis
Nursing Diagnosis - Analyzing patient data to identify strengths and weaknesses. Describe patient problems nurses can treat independently.
Prioritized as
High - Threat to human life
Medium - Non-Threatening
Low - Not specifically related to current health problem.
Components of Diagnosis
Label/Definition - Should be clear, concise, and define the problem.
Related Factors - Factors that relate directly to the problem
Defining Characteristics - Evidence/Characteristics Subjective/Objective Data supporting why a problem is identified
How to look up a nursing diagnosis (asthma)
Step 1. Look up medical diagnosis (asthma)
Step 2. Once there lookup possible reasons behind the problem (does not know how to use inhaler)
Step 3. Lookup nursing diagnosis (knowledge deficit)
Implementing Guidelines
Re-assess patient before implementing plan to see if action is still necessary
Modify nursing intervention to align with patient developmental and psychosocial backgrounds, ability and willingness to participate, response to previous progressions in nursing.
Develop a repertoire of skilled nursing interventions. The more you can choose from the more likelihood of success.
The Six Aims of Implementation
Safe: Avoid Injury
Effective: Avoiding over and under use
Patient Centered: Response to patient needs, preferences, and values
Timely: Reducing waits and delays
Efficient: Avoiding waste
Equitable: Providing care that does not vary in quality between patients.
Categories of Outcomes
Cognitive - Increase in patient knowledge
Psychomotor - Patient achieved new skills
Affective - Changes in patient values, beliefs and attitudes
Physiologic - Physical changes in patient
SMART Goals
S - Specific M - Measurable A - Attainable R - Realistic (goals are relevant to patient condition and patient life) T - Time-bound (Set deadlines)
Variables Influencing Outcome Achievement
Developmental Stage - Can patient follow instructions and are they ready to learn
Nurse Variables - Level of experience, creativity, and time
Resources - Adequate supplies and staff, patient access to nutrition, patient ability to afford treatment
Current standards of care - Does the plan align with current standards and policies.
Research findings - Is there evidence in research to validate plan of care.
Evaluation
Purpose is to allow patient achievements to dictate future nurse-patient interactions.
Actions are based on patient response to care plan. Modifications are needed if patient has difficulty achieving a goal.
5 Elements of Evaluation
- Evaluate Criteria and Standards
- Collect data to see if certain criteria and standards are met
- Interpret and summarize findings
- Documenting judgement
- Terminating, continuing, or modifying plan
Criteria/Standards
Criteria - Describes acceptable level of performance as stated by nurse/patient
Standards - Levels of performance expected by nursing staff and established authority.
