FUNDA: NURSING PROCESS - LEADERSHIP Flashcards
method of planning
and providing individualized nursing care.
NURSING PROCESS
8 characteristics of the nursing process
- Cyclic and Dynamic Nature
- Client Centeredness
- Focus on Problem Solving
- Decision Making
- Interpersonal and Collaborative Style
- Universal Applicability
- Use Of Critical Thinking
- Use Of Clinical Reasoning
year and people who coined nursing process
1955; Lydia Hall & Dorothy Johnson
first people to use the nursing process and year
Orlando (1961) & Ernestein Weidenbach
(1963)
nursing process was formally
introduced as a tool for nursing practice.
1967
______ & ______ identified 4 steps in the process:
implementation was added
Yura & Walsh
first to introduce term nursing diagnosis
Fry
In _____, ______ & ______ met with the NANDA-I. Nursing diagnosis was added as a separate & distinct step in nursing process.
Gebbie and Lavin (1974)
Year that ANA included outcome identification in the planning phase of the process.
1991
phases of the nursing process
assessment, diagnosis, planning, implementation, evaluation
Is the systematic & continuous collection,
organization, validation and documentation of
data or information
assessment
Is carried out during all phases of the nursing
process.
assessment
type of assessment: performed within a specified time after admission to healthcare facility & done to establish a complete database for problem identification, reference & future comparison.
initial assessment
approaches to initial assess.
head to toe, body systems, combination
assessment: performed to determine status of a specific problem identified in an earlier assessment
problem-focused assess.
performed during physiologic or psychologic
crisis of the client & to identify life-threatening problems, new or overlooked problems
emergency assess.
done several months after initial assessment to compare the client’s status to baseline data previously obtained.
Time-lapsed reassessment
assessment involves?
collecting, organizing, validating, interpreting, documenting data
referred to as baseline information of the client
database
referred to as baseline information of the client
database
referred to as baseline information of the client
database
2 sources of data
primary and secondary
2 sources of data
primary and secondary
types of data
subjective and objective
aka signs or overt data
objective data
aka symptoms or covert data
subjective data
data collected through interview
subjective
data collected through interview
subjective
data collected through interview
subjective
methods of collecting data
interview, observation, PE
3 frameworks used to organize data
- Gordon’s 11 Functional Health Pattern Framework
- Orem’s Self-care Model
- Roy’s Adaptation Model
“Double-checking” or verifying data to confirm that
it is accurate and factual
validating data
Assessment data must be recorded and reported.
documenting data
Assessment data must be recorded and
reported.
nursing diagnosis phase
refers to the reasoning process
diagnosing
statement or conclusion regarding the
nature of a phenomenon
diagnosis
standardized NANDA names for the
diagnoses
diagnostic labels
causal relationship between the problem &
its related or risk factors
etiology
is a clinical judgment by the physician that
determines a specific disease, condition or
pathological state.
medical diagnosis
is a clinical judgment about individual,
family, or community responses to actual
or potential health problems/life processes.
nursing diagnosis
what is NANDA?
North American Nursing Diagnosis
Association (NANDA),
purpose of NANDA
to define, refine, and promote a taxonomy of
nursing diagnostic terminology of general
use to professional nurses
types of nursing diagnosis
actual, risk, wellness
a client problem at the time of assessment
actual diagnosis
problem does not exist but the presence of
risk factors indicates that a problem is
likely to develop if unattended.
risk diagnosis
human responses to levels of wellness in
an individual, family or community that
have a readiness for enhancement.
wellness diagnosis
process of designing an action plan through
which lifestyle behaviors can be prevented,
reduced or eliminated.
planning phase
End product of the planning phase is the ____
NURSING CARE PLAN.
objectives should be:
specific, measurable, attainable, realistic, time-bounded
an action performed
by the nurse that helps the client achieve the
results specified by the goals and expected
outcomes.
nursing intervention
consists of doing and
documenting the activities that are the specific
nursing actions needed to carry out the
interventions.
implementation phase
skills inv. in implementation phase
cognitive, interpersonal, technical skills
defined as a planned, ongoing, purposeful
activity in which clients & healthcare
evaluation phase
takes place at the end of the learning process
to ascertain if the objectives have been
achieved and competencies developed.
summative evaluation
provides information about learning needs of
clients and where additional instruction is
needed.
formative evaluation
Effective communication among health
professionals is vital to the quality of client
care. Health personnel communicates through
discussion, reporting, and recording.
documentation
