220 unit 2 Flashcards
Nursing Process
a systematic method that directs the nurse and patient.
Assessing
Description - collection, validation, and communication of patient data. Purpose - make a judgement about the pt health status, ability to manage his or her own health care, and need for nursing. Activities - Establish database, update data, validate data, and communicate data.
Diagnosing
Description - analysis of pt data to identify pt strength and health problems that independent nursing intervention can prevent or resolve. Purpose - devlop a priotized list of nursing diagnoses. Activities - inter[ret and analyze pt data, identify pt strength and health problems, formulate and validate nursing diagnoses, devlope prioritized list of nursing diagnoses.
Outcome identification and planning
Description - specification of pt outcome to prvent, reduce or resolve the problesm identified in the nursing diagnoses, and related nursing intervention. Purpose - devlop an individualized plan of nursing care. Identify pt strength that can be tapped to facilitate achievement of desired outcome. Activites - establish priorities, write out come and devlope an evaluative strategy, select nursing interventions, communicate plan of nursing care.
Implementing
Description - carrying out the plan of care. Purpose - assist pt to achieve desired outcomes promote wellness, prevent disease and illness, restore health, and facilitate coping with altered functioning. Activities - Carry out the plan of care, continue data collection and modify the plan of care as needed, document care.
Evaluating
Description - measuring the extend to which the pt has achieved the outcomes specified in the plan of care. Purpose - continue, modify, or terminate nursing care. Activities - Measure how well the pt has achieved desired outcomes, idntify factors that contribute to the pt success or failure, modify the plan of care.
Quality Assurance Program (QA)
an ongoing systematic process designed to evaluate and promote excellence in the health care provided to clients
standardized care plan
defined as a pre-determined menu of interventions for a particular patient situation. Translation is defined as depicting intervention evidence accurately and with sufficient granularity to ensure that an intervention can be delivered with fidelity
