Nursing Process Flashcards
Nursing Process
A critical thinking process that professional nurses use to apply the best available evidence to caregiving and promoting human functions and illnesses.
Systemic method of providing care to our client
Nursing Process
Purposes of Nursing Process
To identify a client’s health status and actual or potential health care problems or needs.
To established plans to meet the identified needs.
To deliver specific nursing interventions to meet those needs.
Components of Nursing Process
Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation
Characteristics
Cyclic- repeated process
Dynamic in nature- ongoing process
Client centeredness- plan of care is organized
Focus on problem-solving and decision making- informed clients, based on facts, data, and evidences
Interpersonal and collaborative style
Universal Applicability
Use is critical thinking and clinical reasoning
Assessment
Systematic and continuous collection, organization, validation and documentation of data.
Types of Assessment
- Initial Nursing Assessment
- Problem-focused Assessment
- Emergency Assessment
- Time-lapse Assessment
Initial Nursing Assessment
Performed within specific time
Example: Admission of Client
Problem-focused Assessment
Determine the status of a specific problem identified on an earlier assessment.
Example: hourly checking of fever client
Emergency Assessment
During emergency situation to identify any life-threatening situation.
Example: Rapid assessment of an individuals airway, breathing status and circulation during cardiac arrest
Process of gathering information about a client’s status.
Data Collection
Convert data, clear only to the person affected and can be described only by that person.
Subjective Data
Overt data, are detachable by an observer or can be measured or tested against an accepted standard.
Objective Data
Time-lapse Assessment
To compare the client’s current health status with data previously obtained.
Sources of Data
Primary and Secondary
It is the direct source of information.
Example: The patient verbalizes, “ My stomach is excruciating”.
Primary Data
Indirect source of information.
Secondary Data
Methods of DATA COLLECTION
Observation, Interview , and Examination
Gathering by using the senses
Observation
a planned communication
Interview
Types of Interview
Direct interview- highly structured, directly asked
Indirect interview - client controls the interview
Stages of an Interview
- The opening or introduction
- The body or development
- The closing
A systematic data collection method to detect health problems
Examination
Nursing health nursing or history assessment form. Interpretation of data.
Organization of data
Validation of data
The information gathered during the assessment is double checked to confirm that it is accurate and complete.
To complete the assessment phase, the nurse records client data.
Documentation of data
Assessment Process
Collecting, organizing, validating, and documenting data
Diagnosis
Nurses use critical thinking skills to interpret assessment data to identify client problem.
Clinical judgement concerning a human response to health condition/processes of life, or a vulnerability for that response by an individual, family group, or community
North American Nursing Diagnosis Association
Components of NANDA
Problem statement, Etiology, and Defining characteristics
Acute Pain-
Related to abdominal surgery-
As evidences by patient discomfort and pain scale-
Problem statement
Etiology
Defining characteristics
Status of nursing diagnosis
Actual diagnosis, possible diagnosis, risk nursing diagnosis, the syndrome diagnosis, a d wellness diagnosis
A client problem that is present at the time of the nursing assessment.
Actual diagnosis
A problem may be present, but requires more data collection to rule out or confirm it’s existence
Possible diagnosis
Clinical judgement that a problem may develop or does not exist, but the presence of risk factors indicates that a problem may develop
Risk nursing diagnosis
Clusters of problems predicted to be present because of an event situation
The syndrome diagnosis
Health-related problemat which a healthy person obtains nursing assistance to maintain or perform at a higher level
Wellness diagnosis
Nursing Diagnosis
Statement of nursing judgement that made by the nurse, their education licensed to treat.
Made by a physician
Medical diagnosis
Ineffective breathing
Activity intolerance
Acute oain
Disturbed body image
Asthma
Cerebrovascular accident
Appendicitis
Amputation
Planning
Process of prioritizing, identifying, selecting, ND documenting.
Process of formulating client’s goals and deciding the nursing interventions required to prevent, reduce, or eliminate the client’s health problems.
Types of planning
- Initial planning
- ongoing planning
- Discharged planning
Done after the initial assessment
Initial planning
Continuous planning. Done by individual nurses
Ongoing planning
Needs after the discharge. Process or anticipating client after discharge, medication of clients.
Discharged planning
- Setting Priorities
Prioritization - Establishing client goals/ desired outcomes
Goal
Outcome
Planning Process
Planning by deciding which nursing diagnosis requires attention first, second and so on.
Setting Priorities
- High Priority- first priority, life threatening condition
- Medium Priority- health threatening condition
- Low Priority- Physiological needs, long term period
Maslow’s Pyramid
Nurses set goals for each nursing diagnosis
Establishing client goals/ desired outcomes
Expected or desired outcomes, management of diagnosis if it is appropriate
Goal
Kinds of goals
Short term goals and long term goals
Outcomes achievable in a few days to 1 week or a few hours
Short term goals
Characteristics of short term goals
Specific, Measurable, Accompanied by a target date, Realistic, Time-bound, Client-centered
Takes weeks or months
Long term goal
Clients needs consistency and continuity of care to achieve goals.
Communicating the Plan of z
CARE
-Carrying out the plan
-Consists of doing and documenting the activities
Implementation
The process of implementation
-Implementing the nursing interventions
Selecting Nursing Intervention
Any treatment that the nurse performs to improve patient health
Nursing Intervention
Types of Nursing Interventions
- Independent Interventions
- Dependent Interventions
- Collaborative Interventions
Independent Interventions
Activities that nurses are licensed to initiate on the basis of their knowledge and skills
Activities carried out under the orders or supervision of a licensed physician
Dependent Interventions
Actions that nurses carries out in collaboration with other health team members.
Collaborative Interventions
Nursing Care Plan
A written or computerized information about the client’s care.
A planned, ongoing, purposeful activity in which the murse determines
Evaluation
The client’s progress towards achievement, goals/outcomes and the effectiveness of the nursing care plan.
Evaluation outcome
Nursing Health Assessment
Gathering of information about the physiological, sociological, and Spiritual by a client.
Holistic/overall aspect of an individual.
-In conducting a comprehensive health assessment nurses encompasses the physical, psychological, social, and spiritual health.
-A comprehensive health assessment can be performed as client makes contact within the health care system.
-A comprehensive health assessment can be performed as client makes contact within the health care system.
Theoretical Basis of Health Assessment
Basic functions: eating, walking, breathing.
Factors: lifestyle, diet, physical activity, behavior
Physical health
Involves the intellect but how your client response to your questions. Emotions and behavior of client.
Psychological health
Relation to your family, friends, and colleagues. Relationships and interactions with other.
Social dimension of health
A comprehensive that focuses on the belief of the higher being, personal interventions, meaning of life, and moral decisions of life.
Spiritual Health
Components of focus health assessment
General survey, taking vital signs , and assessing specific areas that relate to the problem.
Goal of Health Assessment
To establish a data base for the client’s normal ability, risk factors, and current alteration.
A complete assessment can provide?
An adequate database
Framework of Health Assessment
- Functional health framework
- Head to toe Framework
- Body System Framework
-Evaluates the effects of the mind, body, and environment in relation to person’s ability to perform the ADL.
-Marjorie Gordon’s 11 functional health patterns
Functional Health Framework
A system for collecting data in an organized manner, starting from the head and proceeding systemically downward to their toes
Head to toe Framework
Medical practitioners commonly used it as it focuses on the pathophysiology involved within specific organ body systems.
Body System Framework
