Nursing Process Flashcards
is a systematic and rational method of planning and
providing individualized nursing care to patient. (Berman et al., 2016, p. 181)
Nursing Process
The Nursing Process include
assessing , diagnosing, planning, implementing and
evaluating.
is the systematic and continuous collection, organization, validation and documentation of data.
Assessment
is the process of interpreting and analysing assessment data to identify clients strengths and problems.
Diagnosis
is the deliberate process of identifying nursing interventions to prevent, reduce or eliminate the client’s
nursing problem.
Planning
is the action phase in which the nurse performs the nursing interventions and document the
care needed.
Implementation
is the a planned, ongoing and purposeful activity to determine the client’s progress, the achievement
of the goals and the effectiveness of the nursing care plan.
Evaluation
- Collect data to identify the client’s health status.
- Identify the client’s actual or potential nursing problems arising from the medical problem.
- Create a Plan of Care that will meet the needs and solve the nursing problems.
Purposes of the Nursing Process
- Cyclic & Dynamic
- Client-centeredness
- Focus on problem solving and decision-making
- Goal-oriented
- Interpersonal process & collaborative
- Use of critical thinking and clinical reasoning
- Universal applicability
Characteristics of the Nursing Process:
is collected via personal communication
subjective data
is collected via observations
Objective data
There are 4 Main Activities performed in assessment:
1.Collection of Data
2.Organization of Data
3.Validation of Data
4.Documentation of Data
is the systematic and continuous collection, organization, validation and
documentation of data.
Assessment
There are 4 types of assessment;
Initial, Problem-focused, Emergency and Time-lapsed
assessment.
contains all the information about a client, it includes physical assessment, history,
physical examination, results of laboratory and diagnostic tests and other information
contributed by other health care professional.
database
data are apparent only to the person affected and can be described or verified only by that
person.
Subjective
are detectable by an observer and can be measured or tested against
an accepted standard.
Objective Data
Sources of data include
client, support people, client records, health care professionals and
literatures.
methods include observation, interview and physical examination.
Data Collection
for organization of data depends on the health care institution but the most
commonly used frameworks include Body Systems Model, Maslow’s Hierarchy of Needs and
Developmental Theories.
Frameworks
To complete the assessment process,
the nurse must record the collected data in the patient’s
record.
TYPE OF ASSESSTMENT - TIME PERFORMED: INITIAL
Performed within a specified time
after admission to a HC Agency.
TYPE OF ASSESSTMENT - TIME PERFORMED: PROBLEM FOCUSED
Ongoing process integrated within
nursing care.
TYPE OF ASSESSTMENT - TIME PERFORMED: Emergency
During any physiological or
psychological crisis of the client.
TYPE OF ASSESSTMENT - TIME PERFORMED: Time-lapsed
Several months after initial
assessment.
TYPE OF ASSESSTMENT - PURPOSE: Time-lapsed
To compare the client’s current status
to baseline data previously obtained.
TYPE OF ASSESSTMENT - PURPOSE: Emergency
To identify life-threatening problems.
To identify new or overlooked
problem.
TYPE OF ASSESSTMENT - PURPOSE: Problem-
focused
To determine the status of a specific
problem identified in an earlier
assessment.
TYPE OF ASSESSTMENT - PURPOSE: Initial
To establish a complete database for
problem identification, reference and
future comparison.
TYPE OF ASSESSTMENT - EXAMPLE - INITIAL
Nursing admission
assessment.
TYPE OF ASSESSTMENT - EXAMPLE - PROBLEM FOCUSED
Hourly assessment of client’s
fluid intake and urinary
output in an ICU.
TYPE OF ASSESSTMENT - EXAMPLE -Emergency
Rapid assessment of ABC
after cardiac arrest.
TYPE OF ASSESSTMENT - EXAMPLE -Time Lapsed
Reassessment of a client’s
functional health problem in
a home care or out patient
setting.
is “ A clinical judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group or community”.
diagnosis
To define, refine and promote a taxonomy of nursing diagnostic terminology for general use of professional
nurses.
PURPOSE OF NANDA INTERNATIONAL:
There are 3 Main Activities performed in diagnosis:
- Analyze the data
- Identify health problems
- Formulate diagnostic statement
inadequate amount, quality, not sufficient, incomplete
- Deficient-
made worse, weakened, damage, reduced, deteriorated
Impaired-
lesser in size, amount or degree
Decreased-
not producing the desired effect
Ineffective-
Identifies one or more probable causes of health problem, gives __________________________ therapy and
enables the nurse to individualize the client’s care.
direction to the required nursing
client’s signs and symptoms
ACTUAL NDX-
no subjective and objective data
RISK NDX-
Components of NANDA Nursing Diagnosis: 3 Parts (Use for actual problem)
- Problem
- Etiology
- Signs and Symptoms
Components of NANDA Nursing Diagnosis: 2 Parts (Use for risk and syndrome)
- Problem
- Etiology
Components of NANDA Nursing Diagnosis: 1 Part (Use for health promotion)
- Problem
There are 4 types of diagnosis-
Actual Diagnosis, health Promotion Diagnosis, Risk
Diagnosis and Syndrome Diagnosis.
In formulating the ____________________, the nurse can use the 3 Parts, 2 Parts and 1 Part
Component.
nursing diagnosis
is “ A clinical judgment concerning a human response to health conditions/life
processes, or a vulnerability for that response, by an individual, family, group or
community”.
Diagnosis
