Nursing Process 1 Flashcards
nursing process
systematic method by which nurses plan and provide care for patients
a problem-solving approach that enables the nurse to identify patient problems and potential problems
Use ADPIE (Assessment // Data collection // Planning // Implementation // Evaluation)
assessment
the first step in delivering nursing care
dynamic way to collect data, includes physiological, psychosocial, sociocultural, spiritual, economic, and lifestyle
biographic data
provide information about the facts and events of a person’s life
case management
encompasses planning, coordination of care, and patient advocacy in providing quality, cost-effective outcomes for the patient
clinical pathway
multi-disciplinary plan that incorporates evidence-based practice guidelines for high-risk, high-volume, high-cost types of cases while providing for optimal outcomes and maximized clinical efficiency
collaborative problems
health-related problems that the nurse anticipates based on the condition or diagnosis of the patient; both health-care provider prescribed and nursing prescribed interventions
diagnose
to identify the type and cause of a health condition; only a physician or other medically qualified health care provider can provide a medical diagnosis
The LVN and RN observe and collect the data for analysis where the RN analyzes and interprets data to identify health problems that the nurse can treat – nursing diagnosis
database
a large store or bank of information for the patient; established through physical exam and completed nursing health history
defining characteristics
clinical cues, signs, and symptoms that furnish evidence that the problems exist
objective data
observable and measurable signs (i.e. measuring BP, observe edema, redness, size of lesion)
evaluation
determination made about the extent to which the established goals have been achieved
[1] Review patient goals
[2] Reassess patient to gather data
[3] Compare actual outcome with desired outcome; make critical judgement of whether the goal was met
goal
patient centered, includes measurable verbs (list, walk, demonstrate, verbalize) to indicate precise behavior the nurse anticipates hearing or seeing
“patient will have intact skin within 3 wk. (Note: intact skin is a reversal of impaired skin)”
implementation
phase of the nursing process where the plan is put into action to promote goal-achievement; nurse should ensure plan is carried out timely and safely
managed care
health care systems that have control over primary health care services and attempt to trim down costs by reducing overlapping or unnecessary services
nursing interventions
activities that promote achievement of desired patient goal
include nurse prescribed and physician prescribed activities
planning
priorities of care are established and nursing interventions are chosen to best address the patient problem statement
standardized language
terms that have the same definition and meaning regardless of who uses them; provides consistent and effective communication
nursing-sensitive patient outcomes
NOC - Nursing Outcome Classification; measures the effects of nursing care, the effort of a group to create a standardized system with an organized structure to name and measure
variance
if a patient does not achieve the desired outcome, it’s considered a variance.
must be evaluated to determine why a patient did not achieve the desired outcome
