Into to the Nursing Process Flashcards
5 key principles of the nursing process
1) Critical thinking
2) Patient centered care
3) Goal oriented tasks
4) Evidence-based practice
5) Nursing intuition
The nursing process, as a __ __ model, demonstrated competency in the nursing practice and forms the foundation for clinical __ __
critical thinking
decision making
5 sequential steps of the nursing process
1) Assessment
2) Analysis
3) Planning
4) Implementation
5) Evaluation
Gather subjective and objective data
Assessment
Analyze, validate, and cluster patient data to identify problems
Analysis
Identifies goals that are realistic, measurable, patient focused, with specific outcomes
Planning
Initiates nursing interventions designed to help patient establish goals
Implementation
Determines if patient’s foals are met, examines effectiveness of interventions
Evaluation
3 essential characteristics of nursing process
Organized
Outcome oriented
Collaborative
3 more essential characteristics of nursing process
Dynamic, changing overtime
Requires knowledge application, analysis, critical thinking
Universally adaptable to all kinds of patients
Systemic collection of patient Dara, 1st step in providing care
Assessment
Assess state of patient’s physical, psychological, emotional, environmental, sociocultural, economic and spiritual health
Holistic assessment
Data obtained directly from the patient
Primary data
Data collected from family, caregivers, HCPs, medical record
Secondary data
Information that is seen, measured, or tested
Objective data
Information collected from the patient
Subjective data
Second step in nursing process
Analysis
Nurses’s clinical judgement based on data, a problem, or response to a problem
Nursing diagnosis
An actual or potential problem or response treated by HCPs/team
Collaborative problem
Who should be involved in determining nursing diagnoses if possible?
The patient
naming systems aka
nomenclatures
Standardized nursing language system used for point-of-care documentation
International Classification for Nursing Practice (ICNP)
What can the ICNP be used to identify? (3)
Diagnoses, interventions, outcomes
To determine if problems are improving, declining, or unchanged
Purpose of evaluation
3 functions to effectively evaluate patient goals
Examine results
Compare achieved effect with goals and outcomes
Recognize errors
Last step of the nursing process
Evaluation
5 steps to prepare for implementation
1) Reassess patient
2) Review/revise POC
3) Organize resources and care delivery
4) Anticipate and prevent complications
5) Implement nursing interventions
Performed on behalf of patient
indirect care
Performed on or with patients
direct care
Example of indirect care
Provider prescribes a special diet
Example of direct care
ambulating a patient
Fourth step of the nursing process
Implementation
Collaborative interventions
Requires combined knowledge of multiple HCPs
Needs order from the HCP
HCP initiated intervention
Nurse-initiated interventions
Does not require HCP, nurse can do alone
3 types of nursing interventions
nurse-initiated
HCP-initiated
collaborative interventions
Measurable changes
outcomes
Goals may extend over weeks or months
long-term goals
Goals may be achieved in 1 week or less
short-term goals
SMART stands for…
Specific Measurable Attainable Realistic Timed
Goals and outcomes should be written according to the
SMART acronym
Often focused on long term patient needs can affect future well being if not addressed
Low importance priority
Intermediate importance priority
Non emergent, but important to address to prevent complications
High important priority
If not addressed, can results in patient harm or harm to others
Priority setting is
Organization of a vision for a desired patient outcomes, NOT a list of tasks
Third step in the nursing process
Planning
The nursing diagnoses reflects clinical judgements about…
Patient problems
health promotion
Vulnerability/risk for problems
