Chapter 2 Nursing Process Flashcards
The nurse collects patient health data.
Assessment
The nurse analyzes the assessment data to determine diagnoses.
Diagnosis
The nurse develops a plan of care that prescribes interventions to attain expected outcomes.
Planning
The nurse implements the interventions identified in the plan of care.
Implementation
The nurse evaluates the patient’s progress toward attainment of outcomes.
Evaluation
What are three types of assessments:
Database assessment
Focus assessment
Functional assessment
Obtained on admission;
Consists of predetermined questions and systematic head-to-toe examination
Database assessment
Compiled throughout subsequent care;
Consists of unstructured questions and a collection of physical assessments;
Repeated each shift or more often
Focus assessment
Completed within the first 14 days of admission
Functional assessment
1) Developed from the problem portion of the diagnostic statement
2) Client-centered, reflecting what the client will accomplish, not what the nurse will accomplish
3) Measurable, identifying specific criteria that provide evidence of goal achievement
4) Realistic, to avoid setting unattainable goals, which can be self-defeating and frustrating
5) Accompanied by a target date for accomplishment (the predicted time when the goal will be met), which establishes a timeline for evaluation
short-term goals characteristics:
The Nursing Scope and Standards of Practice
Who: “Person who is educated, titled, and has active licensure to practice nursing.
What: Nursing is the protection and promotion of health and abilities; prevention of illness; facilitation of healing; and alleviation of suffering through the diagnosis and treatment of human response.
Where: Wherever there is a patient in need of care.
When: Whenever there is a need for nursing knowledge and expertise.
Why: The profession exists to achieve the most positive patient outcomes with nursing’s social contract and obligation to society.
Characteristics of the Nursing Process
1) Practice within your scope of Practice
2) Development of critical thinking with the use of evidence-based Practice
3) Planned and organized
4) Focused on client/client-centered
5) Set goals to achieve client outcomes
6) Prioritize care on the most immediate need first
7) Everchanging must be able to look at data and outcomes and change focus
Primary source of data
Client or patient
The secondary source of data
Family, reports, test results, and information in past medical records
The “PLANNING” phase of the nursing process
Prioritize Needs
Maslow’s Hierarchy
Short Term Goals
Long term goals
