Module 3 Nursing Process Flashcards
Collecting, organizing, validating, and documenting client data
Assessing
Analyzing and synthesizing data
Diagnosing
Determining how to prevent, reduce, or resolve the identified priority client problems;
how to support client strengths; and
how to implement nursing interventions in an organized, individualized, and goal-directed manner
PLANNING
Carrying out (or delegating) and documenting the planned nursing interventions
IMPLEMENTING
Measuring the degree to which goals/outcomes have been achieved and identifying factors that positively or negatively influence goal achievement
EVALUATING
establish a database about the client’s response to health concerns or illness and the ability to manage health care needs
ASSESSING
identify client strengths and health problems that can be prevented or resolved by collaborative and independent nursing interventions
To develop a list of nursing and collaborative problems
DIAGNOSING
develop an individualized care plan that specifies client goals/desired out-comes, and related nursing interventions
PLANNING
assist the client to meet desired goals/ outcomes; promote wellness;
prevent illness and disease;
restore health;
and facilitate coping with altered functioning
IMPLEMENTING
determine whether to continue, modify, or terminate the plan of care
EVALUATING
STEPS IN WRITING A NURSING CARE PLAN
- Data Collection
- Data Analysis and Organization
- Formulating your Nursing Diagnosis
- Setting Priorities
- Establishing Client Goals and Desired
- Selecting Nursing Interventions
- Providing Rationale
- Evaluation
- Putting it on Paper
Validation
Double checking or verifying data to confirm that it is accurate and factual.
Cues
Subjective and objective that can be directly observed by the nurse
Inferences
Are nurses interpretation or conclusions made based on the cues
