Nursing Process Flashcards
Is a systematic, rational method of planning and providing individualized nursing care.
Nursing process
Who originated the term nursing process? When?
Hall (1955), Johnson (1959), Orlando (1961), Widenbach (1963)
The use of the nursing process in clinical practice gained additional legitimacy in?(year) when the phases were included in American Nurses Association (ANA)
1973
Characteristics of the nursing process:
Cyclic and dynamic
Client-centered
Focused on problem solving and decision making
Interpersonal and collaborative style
Universal applicability
Data in each phase provides data in the next phase.
Cyclic and dynamic
Regularly repeated event or sequence of events that are continuously changing.
Cyclic and dynamic
The nurse organizes the plan of care according to the client problems and needs rather than nursing goals.
Client-centered
It is involved in every phase of the nursing process.
Decision-making
This facilitates the individualization of the nurse’s plan of care.
Decision-making
It requires the nurse to communicate directly and consistently with clients and families to meet their needs.
Interpersonal and collaborative
Obtaining an information and that clarifies the nature of the problem and suggests possible solutions.
Problem solving
A critical thinking process for choosing the best actions to meet a desired goal.
Decision-making
It is an adaptation of problem solving and decision making.
Nursing process
Nursing process is used as a framework for nursing care in all types of healthcare settings, with clients of all age groups.
Universal applicability
Intellectually disciplines process of actively and skillfully conceptualizing, applying, analyzing, and/or evaluating information gathered from, or generated observation, experience, reflection, reasoning or communication, as a guide to belief and action.
Critical thinking
Collection, organization, validation, documentation of data
Assessment
Purpose of assessment
To establish database about the client’s response to health concerns or illness and the ability to manage healthcare needs
Analysis of data
Identification of health problems, risks, and strengths
Formulation of diagnostic statements
Diagnosing
Prioritization of problems/diagnoses
Formulation of goals/desired outcomes
Planning
Selection of nursing interventions
Writing of nursing orders
Planning
Purpose of planning
To develop a health care plan reflective of specific objective.
Reassessment of the client
Determination of the nurse’s need for assistance
Implementation
Implementation of nursing interventions
Supervision of delegated care
Implementation
Documentation of nursing activities
Implementation
Collection of data related to outcomes
Comparison of data with outcomes.
Evaluation
A systematic and continuous collection, organization, validation, and documentation of data (information).
Assessment
The process of gathering information about client’s health status.
Data collection
Covert data
Symptoms
Overt data
Signs
Apparent only to the person affected and can be verified only by the person.
Subjective data
Detectable by an observer or can be measured or tested against accepted standard.
Objective data
Conscious, deliberate skill involving the use of senses.
Observation
Planned communication or a conversation with a purpose.
Interview
Highly structured and elicits specific information.
Directive interview
Nurse allows client to control purpose, subject matter and pacing.
Non-directive interview
Major method used in the physical health assessment.
Examining
A systematic data collection method that uses observation to detect health problems through the use of the techniques: inspection, auscultation, palpation, and percussion.
Physical assessment
Information that does not change over time such as race or blood type.
Constant data
Data that can change quickly, frequently, or rarely and include such data as blood pressure, level of pain, and age.
Variable data
The nurse uses the written format or computerized format that organizes the assessment data systematically.
Nursing health history
Nursing assessment or nursing databases form