Nursing Process Flashcards
nursing process
human response to __________ or ___________ problem
actual, potential
nursing process
holistic
scientific
EBP
individualized
analyze information
critical thinking
mental process of
recognizing, analyzing, applying and evaluating information to reach a conclusion
clinical thinking
use critical thinking in a clinical setting to make nursing care decisions based on EBP
standardized language
always using the same wording
do nurses treat the medical diagnosis
no
benefits of standardized nursing language
defines nursing contribution and impact in healthcare
defines what nurses do
gives nurses more EB outcomes and interventions
easily integrated into EMR
standardizes knowledge for nursing curriculum
promotes nursing research
ADPIE
assessment
diagnosis
planning
implementation
evaulation
what step comes first
assessment
what comes after assessment
diagnosis
what are the 2 parts of diagnosis
actual- 3 part
risk - 2 part
what comes after diagnosis
planning
what are the two parts of planning
patient outcomes
nursing interventions
what comes after planning
implement
what comes after implementation
evaulation
what does evaluation lead back to
patient outcomes
what are the types of assessment
inital
- admission
- shift
focused
time lapsed
what is an admission assessment
completed within 8 hours of admission (mandated by joint commission)
baseline for hospitalization
what is a shift assessment
what you do at the beginning of shift
baseline for day
what is a focused assessment
only focus on one system
a patient returns a few days after an appointment for asthma unplanned
what assessment
focused
what is a time lapsed assessment
treatment for specific time
purposely come back after certain time
a patient returns for a follow up appointment 2 months after a previous appointment for COPD
what assessment
time lapsed
what is the best source for data
patient
if the patient is not available what is the next best source for data
family and significant others
if the patient and family/significant others are not available what is the next best source for data
patient record
if the patient, family/significant others, records, are not available what is the next best source for data
other healthcare professionals
subjective
what the patient says
objective
measurable and observable
nursing diagnosis
clinical judgment about an individuals responses to actual or potential health problems
nursing diagnosis provides the basis for selection of __________ _______ and __________ ______________ to achieve the set outcomes
patient outcomes, nursing interventions
steps in diagnosis process
- create a list of suspected problems
- name actual and problems/diagnoses and clarify what is causing or contrubituing to them
- determine risk factors that must be managed for a risk DX
- confirm defining characteristics for an actual DX
- prioritize nursing diagnoses