Nursing Process Flashcards
what are the 5 steps of the nursing process?
Assessment, Diagnoses, Plan, Implementation and Evaluation (ADPIE)
What does assessment consist of?
systematic data collection, determining patient current and past status and critical thinking
what are the types of data?
Objective (patient’s blood pressure) and Subjective data (how are you feeling?)
what are the sources of data?
Primary (from patient directly), Secondary (from family members or peers) and Tertiary (evidence-based information, nurse’s own experience)
what is an interview?
an organized conversation with the client, it is a way of exploring and building therapeutic relationships.
what does physical examination consist of?
observation of client’s behaviour, diagnostic and laboratory data, interpreting assessment data and making nursing judgement
what are the steps in data analysis?
recognize patterns or trends by cues, compare with normal standards and make a reasoned decision.
mention some considerations in assessment
cultural assessment (conduct any assessment with cultural safety and humility), indigenous health assessment
what is nursing diagnosis?
means of translating nursing observations and assessment into standard conclusions in a common nomenclature.
what are the types of diagnosis?
Nursing diagnosis, Medical diagnosis and Collaborative problem
what are the types of nursing diagnosis?
Actual nursing diagnosis, Risk nursing diagnosis, Health promotion nursing diagnosis and Wellness nursing diagnoses
why do we use nursing diagnosis?
provides direction for the care plan and selection of nursing interventions, provides a precise definition of the client’s needs, gives all members of health care team a common language to use
what does planning consist of?
Nurse sets client-centered goals and expected outcomes, plans nursing interventions and prioritizes interventions.
what are the 3 classification of priorities?
high-priority nursing diagnoses, intermediate-priority nursing diagnoses and low-priority nursing diagnoses.
what are the 3 phases of nursing care?
initial, ongoing and discharge
what are the 3 goals of care?
Client-centered goal, short term goal and long-term goal
what are expected outcomes?
Specific, measurable change in a client’s status that is expected in response to nursing care
what is implementation?
the initiation or completion of planned actions or nursing interventions.
what are the types of intervention?
nurse-initiated (independent nursing intervention), physician/practitioner-initiated (dependent nursing intervention) and collaborative (interdependent nursing intervention)
what is Nursing Interventions
Classification (NIC) ?
A set of nursing interventions that provides a level of standardization, which enhances communication of nursing care across all health care settings and enables health care providers to compare outcomes
what are the 3 levels of Nursing Interventions Classification (NIC)?
7 domains, 30 classes and 565 interventions
what is concept mapping?
a visual representation that shows connections between a client’s health problems and allows nurses to obtain a holistic perspective of health care needs
what are the 3 implementation skills?
cognitive, interpersonal and psychomotor skills
what does evaluation consist of?
examination of condition or situation, judgement as to whether change has occurred
The evaluation process is based on what two actions?
identify evaluative criteria and standards, collect evaluative data
what are the steps of the evaluation process?
collecting data, identifying evaluative criteria, interpreting and summarizing findings, documenting findings and terminating, continuing or revising the care plan.
mention 3 institutional care plans
computerized care plans, care plans for community-based settings and critical pathways
