Chapter one Nursing Process Flashcards
Nursing Process Steps
1) Assessment: Collect, organize, validate, document data
2) Nursing Diagnosis: Analyze data, Identify health problems, Formulate diagnostic statements.
3) Planning: Prioritize problem/diagnosis, formulate goal/outcome, select nursing interventions, write nursing interventions
4) Implementation: reassess the client, determine the need for assistance, implement nurse interventions, document nursing activities
5) Evaluation: Collect data related to the outcome, compare data with outcomes, relate nursing action to patient goal/outcomes, draw conclusions, continue to modify or terminate plan.
Nursing process- Assessment
Subjective data Current health history Patient signs and symptoms Current medications and concerns Allergies Financial barriers Tobacco, alcohol, and caffeine use Cultural dietary barriers Home safety needs Caregiver needs and support system
Objective data Physical health assessment Laboratory and diagnostic test results Physician’s notes (health history) Measurement of vital signs Patient’s body language
Nursing Process-Nursing Diagnosis
Nursing diagnoses examples:
Acute pain related to surgery
Acute confusion related to adverse reaction to medication
Ineffective health maintenance related to not receiving recommended preventive care
Deficient knowledge related to effects of anticoagulant medication
Noncompliance related to forgetfulness
Ineffective health maintenance related to lack of finances
Nursing Process- Planning
Effective goal-setting characteristics Patient centered Realistic and measurable Reasonable deadlines Acceptable to both patient and nurse Dependent on patient’s decision-making ability Shared with other health care providers, family, and caregivers Identifies components for evaluation
Effective goal-setting examples
The patient will independently administer prescribed dose of 4 units of regular insulin by the end of the fourth session of instruction.
The patient will prepare a 3-day medication recording sheet that correctly reflects the prescribed medication schedule by the end of the second session of instruction.
Nursing Process-Implementation
Implementation of nursing interventions Education Drug administration Patient care Interventions needed for established goals
Factors promoting patient teaching Patient must be ready to learn. Nurse and patient must be fully engaged. Timing is important. Conducive quiet environment Eliminate barriers (pain). Have interpreter if language barrier. Have family member present if patient is forgetful
Factors promoting patient teaching
Tailor teaching to patient’s education level.
Utilize several sessions to avoid overload.
Utilize community resources.
Evaluate patient’s understanding of instruction
Patient teaching: General Side effects Self-administration Diet Cultural considerations
Nursing Process- Evaluation
Determine if goals were met. Determine if teaching objectives were met. Determine need for follow-up. Refer to community resources. Document successful goal attainment
