Chapter 7-Nursing Process Flashcards
Nursing process framework
The nursing process includes sequential but overlapping steps:
Assessment/data collection
Analysis/data collection
Planning
Implementation
Evaluation
What is included an assessment/data collection?
Systematic collection of information about clients present health statuses to identify needs and additional data to collect based on findings.
Examples: Interviews with clients and families, observations, medical history, physical examination, diagnostic and laboratory reports, collaboration with other members of healthcare team.
Subjective versus objective
Subjective is when the client tells the nurse what they feel.
Example: “My shoulder is really, really sore. “
Objective is data the nurse obtained through observation and examination.
Example: client grimaces when attempting to brush their hair with their left arm.
Analysis/data collection
Requires nurses to look at the data and recognize patterns or trends, compare the data was expected standards or reference ranges, arrive at conclusions to guide nursing care.
Planning
These are the goals created contributing to a clients plan of care. Nurses must establish priorities and optimal outcomes of care they can measure and evaluate.
Three types of planning
Comprehensive plan of care for clients on admission.
Ongoing planning throughout the provision of care.
Discharge planning process of anticipating and planning for clients needs after discharge. This begins admission.
How does Maslow’s hierarchy of basic needs contribute to planning?
Nurses participate in priority setting when they identify a preferential order of problems this guides the delivery of nursing care. They can use guidelines such as Maslow’s hierarchy of basic needs.
What are the levels of Maslow’s hierarchy of basic needs?
(Starting at bottom/1st priority)
Physiological
Safety and security
Love and belonging
Self-esteem
Self actualization
Implementation
Implementing interventions to help reach the goals in the planning step.
Must use clinical judgment and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health.
Evaluation
Nurses evaluate clients responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes.
Did we reach the goal? If not reassess.
