Chapter Four Flashcards
Critical Thinking
Skillful reasoning and logical thought to determine the merits of a belief or action
Nursing Process
Decision making framework that is used by all nurses to determine the needs of their patients and decide how to care for them
Care Plan
A documented plan for giving patient care and includes the providers orders, nursing diagnoses, and nursing orders
Critical Thinking
Using skillful reasoning and logical thought to determine the merits of a belief or action
Validate
Ensuring the correctness of something (like the information obtained)
Steps of Nursing Process:
Assessment
Diagnosis
Planning
Implementation
Evaluation
Assessment
Gathering of information through signs and symptoms, patient hx, and both subjective and objective findings.
Will gather information by asking questions, performing head to toe, and reviewing lab and diagnostic results.
Diagnosis
Formulation of nursing diagnosis through analysis of the assessment information that is gathered.
Nursing Diagnosis
Related to the needs or problems a patient is experiencing
Planning
Process of determining priorities and what nursing actions should be reformed to help resolve or manage each patient problem. Nurse also determines expected outcomes for patient to meet for the diagnosis to be resolved as well as realistic time frame for it to happen. Then decides appropriate interventions to resolve each patient problem or nursing diagnosis.
Implementation
Process of taking actions to resolve the patient problems. These are called interventions. When the nurse performs these interventions it is called implementation. The nurse implements the plan to help resolve the patients problems.
Evaluation
Performed when the nurse reflects on the interventions performed and decides whether the patent is now closer to achieving the goals and outcomes set in the planning step. If not, the nurse then revises and changes the interventions and perhaps the goals to better git the needs of the patient.
What is the difference between Medical Diagnosis and Nursing Diagnosis?
Medical is about the disease process, Nursing is about the care of the patient.
Objective Data
Things that you observe, through your senses (or can measure).
Sight, Touch, Smell, Hearing.
Subjective Data
Information that is known only to the patient or family members. (What they say)
I feel nauseated, I have a sharp pain here, I feel anxious. When documenting you would put “the patient states…”
