Nursing process Flashcards
Assessment
Collection, verification, and analysis of data
Activities of daily living (ADL’s)
Activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, and grooming)
Patient centered goal
Reflects a patients highest possible level of wellness and independence in function
Counseling
Direct care method that helps a patient in the problem-solving process to recognize and manage stress and facilitate interpersonal relationships
Data base
The patients perceived needs, health problems, and responses
Data clustering
Set of signs and symptoms gathered during the assessment that you grouped together in a logical way
Data collection
information comes from: the patient through interview, observations and physical examination. Family members or significant others’ reports and responses to interviews. Other members of the healthcare team. Medical record information. Scientific literature.
Defining characteristics
Clinical criteria that are observable and verifiable
Delegation
Non invasive tasks (ADL’s and vitals). Nurses who assigns the tasks are responsible for ensuring that each task is appropriately assigned and completed according to standards of care. The person that was given the task must be competent.
Dependent interventions
Actions that require an order from the physician or another healthcare provider
Etiology
The cause of the nursing diagnosis within the domain of nursing practice
Expected outcomes
A measurable criterion to evaluate goal achievement
Implementation
Begins after the nurse develops a nursing plan, based on clear and relevant nursing diagnoses; designed to achieve the goals and expected outcomes, needed to support or improve the patients health status.
Independent interventions
Actions that a nurse initiates, does not require an order from another healthcare professional
Interdependent interventions
Therapies that require the combined knowledge, skill, and expertise of multiple care professionals
Health Interview
Characteristics: organized convo. Confidential, and focused and systematic.
Medical record
Use of current and past medical records to retrieve info that might be helpful
Medical diagnosis
Illness that reflect alteration of the structure or function of organs or systems
Nursing diagnosis
Addresses human responses to actual or potential problems or processes
Nursing process
A systematic process;The process of problem-solving method of planning and providing individualized care for patients and clients.. Ongoing and something that is done continuously
Standing order
Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients is identified clinical problems
Benefits of nursing process
Unifying concept; provides a framework Communication (in a common language) Individual focus Patient is an active participant Cost effective
Steps of the nursing process
Assessment problem identification (nursing diagnosis) planning implementation evaluation
Sources of data
Primary and secondary
Primary source
Info from the patient
Secondary source
Lab reports, medical record, family etc
Types of data
Subjective and objective data
Subjective data
Patient verbal descriptions of their health problems; only patients provide subjective data
Objective data
Proof, use of senses; observations or measurements on the patient’s health status
Phases of a health interview
Preparatory
Introductory
Working
Termination
Preparatory phase of a health interview
Get everything that is needed
Introductory phase of the health interview
Introduce self, and state purpose
Working phase of the health interview
Gather information needed.. Ask the appropriate questions
Termination phase of the health interview
Let patient know the interview is about to end, summarize what the patient has told you
Problem identification/ nursing diagnosis
Statement of an actual or potential health problem; it is derived from the health assessment data
Nursing diagnosis equation
NANDA problem statement + etiology or R/T + S/SX or AEB
(R/T: related to)
(S/SX: signs/symptoms)
(AEB: as evidence by)
Short term outcome
Objective behavior that you expect the patient will achieve in a short time
Long term outcome
Objective behavior that is expected over a long period
Cue
Information that was obtained through the use of senses
Inference
Your judgment or interpretation of cues
Outcomes must be:
Realistic
Observable
Measurable
High-priority
If untreated, result in harm to the patient or others, example:risk for directed violence, impaired gas exchange, decreased cardiac output
Intermediate priority
Involved non-emergent, non-life threatening needs of patients examples: impaired mobility
Low priority
Not always directly related to specific illness or prognosis but affects patients future well-being
Dependent nursing interventions
actions that require an order from a physician or another healthcare provider
Three levels of critical thinking
Basic, complex, commitment
Basic level of critical thinking
Learners trust that experts have the right answers for every problem
Complex level of critical thinking
Begin to separate themselves from experts; they analyze and examine choices more independently
Commitment
A person anticipates when to make choices without assistance from others and accepts accountability
Concept map
The visual representation that allows you to graphically show the connections between patients many health problems
