Class 7-Nursing Process Flashcards
Nursing process
framework for professional nursing practice/setting a standard of care
Standardized nursing language (NANDA North American nursing diagnosis association)
-defines nursing’s contribution and impact in healthcare. defines what nurses do
-gives nurses more evidence based outcomes and interventions
-easily integrated into EMR
-standardizes knowledge for nursing curriculum (QSEN)
-promotes nursing research
think like a nurse to develop clinical judgement-why learn it?
-prepare for NCLEX
-transform thinking into clinical judgement
-become a self directed thinker
-becoming resilient
-reduce errors in healthcare setting
NGN (next generation) clinical judgement measurement model
-recognize cues
-analyze cues
-prioritize hypotheses
-generate solutions
-take actions
-evaluate outcomes
recognizing cues OR getting the information/assessing
-determine what information you need
-use multiple sources
-eliminate preconceived ideas
-scan the environment
-identify signs and symptoms
-assess systematically and comprehensively
-ensure that you collect accurate information
alignment of the clinical judgement model and the nursing process
-CJM (clinical judgement model)
-nursing process
CJM
-getting the information
-making meaning of the information
-determine actions to take
-take action
-evaluate outcomes and your thinking
Nursing process
-assessment
-diagnosis
-planning
-implementing
-evaluating
ADPIE-nursing process
Assessment
diagnosis (identify problem)(actual=3 part; risk=2 part)
planning (patient outcomes; nursing interventions)
implement
evaluation (patient outcomes)
LOOK AT SLIDE 8
a nursing care plan allows the nurse to:
-INDIVIDUALIZE CARE that maximizes outcome achievement
-SET PRIORITIES
-FACILITATE COMMUNICATION among nursing personnel and colleagues
-PROMOTE CONTINUITY of high-quality, cost-effective care
-EVALUATE PATIENT RESPONSE to nursing care
-CREATE A RECORD used for evaluation, research, reimbursement, and legal reasons
characteristics of nursing assessments
-purposeful
-prioritized
-complete
-systematic
-accurate
-relevant
-recorded in a standard manner
Types of assessment
initial
-admission: in depth; set base line for hospitalization
-shift: baseline for shift; a bit quicker
focused
time-lapsed: coming back at certain time point; pre determined; after specific amount of time; usually more outpatient
sources of data for assessment
-patient
-family and significant others
-patient record
-other healthcare professionals
types of assessment data
subjective
-what the patient feels or says
objective
-measurable and observable