Nursing Process Flashcards
A systematic, client-centered method for structuring the delivery of nursing care.
Nursing Process
Nursing Process…
• Provides structure for __________
nursing practice
Nursing Process…
• Entails gathering and analyzing __________
data
Nursing Process…
• Helps enhance __________
critical thinking
Nursing Process…
• __________ – central figure
Patients
PURPOSES of the NURSING PROCESS
1. To identify client’s (1) __________
2. To identify actual or potential (2) __________ or __________
(1) health status
(2) health care problems or needs
PURPOSES of the NURSING PROCESS
3. To establish plans to meet (1) __________
4. To deliver specific (2) __________ to meet identified needs
(1) identified needs
(2) nursing interventions
Systematic & continuous collection, organization, validation, & documentation of data
Health Assessment
Health Assessment is a __________
continuous process
The focus of Health Assessment: __________
client’s health status
Preparing for Assessment
•Organize (1) _______ and ________
•Organize your (1) __________
•Review (3) __________
•Keep an (4) __________ and avoid __________
(1) equipment and supplies
(2) thoughts
(3) medical record
(4) open mind / judgments
STEPS OF HEALTH ASSESSMENT
• Collection of (1) _______ data
• Collection of (2) _______ data
• (3) _______ of data
• (4) _______ of data
(1) subjective
(2) objective
(3) Validation
(4) Documentation
• Personal information
• Feelings
STEP 1: COLLECTION OF SUBJECTIVE DATA
• Physical symptoms related to body parts
• Past health history
• Family history
• Health and lifestyle practices
MAJOR AREAS OF SUBJECTIVE DATA
• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing
STEP 2: COLLECTION OF OBJECTIVE DATA
• Ensures that the assessment process is not ended before all relevant data is collected
• Ensures documentation of accurate data
STEP 3: VALIDATION OF DATA
• Provides data for all other members of the health care team
STEP 4: DOCUMENTATION OF DATA
Characteristics of the STEPS:
• (1) __________
• Performed (2) __________, at times
(1) Overlapping
(2) concurrently
So, thorough assessment can generate A LOT OF ________.
DATA
• Interpret assessment data
• Identify client strengths & problems
DIAGNOSING
Data Analysis
Problem Identification
Formulation of Nursing Diagnostic Statement
DIAGNOSING
• Actual or potential health problem that independent / interdependent nursing interventions can prevent or resolve
Nursing Diagnosis
Nursing Diagnosis
• Describes a (1) __________; deviations from health, presence of risk factors and areas of enhanced personal growth
(1) continuum of health status
• What do you want to happen?
• How can you make it happen?
Planning
Planning
> Developing a (1) __________
> Nurse works with the client to (2) __________
(1) plan of care
(2) set goals / outcomes
Planning
1. Setting (1) __________
2. Establishing (2) __________
3. Selecting (3) __________
4. Writing individualized (4) __________ on care plan
(1) priorities
(2) client goals
(3) nursing interventions
(4) nursing interventions
In Planning:
1. The most important (1) _______ to the patient
2. (2) _______ of potential problems
3. (3) _______, _______ available, _______, _______ needed
(1) problems
(2) Effect
(3) Costs / resources / personnel / time
• Describes a change in the patient’s health status or functioning
• Expected outcome, predicted outcome, outcome criterion, objective
Goal
Situation: Frail elderly man with a pressure ulcer on his sacral area
Type of Goal: The patient’s sacral area will exhibit no evidence of a pressure ulcer.
Long Term Goal
Situation: Frail elderly man with a pressure ulcer on his sacral area
Type of Goal: At the end of the first week, the patient’s pressure ulcer would have decreased in size by a quarter inch.
Short Term Goal
Guidelines for Writing Goals
S - _______
M - _______
A - _______
R - _______
T - _______
Specific
Measurable
Attainable
Realistic
Time-Bound
Attribute of Goal: The patient will ambulate with assistance from bed to bathroom by tomorrow.
MEASURABLE GOALS
Guidelines for Writing Goals
The goal is (1) ________ with and (2) ________ of other therapies.
(1) congruent
(2) supportive
Guidelines for Writing Goals
• Whenever possible, the goal is important and valued by (1) __________.
• Derive each goal from only (2) __________.
• Keep the goal (3) __________.
(1) the patient, the nurses, and the physician
(2) one nursing diagnosis
(3) short
• Activities the nurse plans and implements to help a patient achieve identified goal
SELECTING NURSING INTERVENTIONS
Components of Nursing Intervention
PDx - Diagnostics
PTx - Therapeutic
PEd - Education or Health Teaching
(Diagnostics)
ex: weighing, VS, Hgt monitoring
PDx
(Therapeutic)
ex: administering of Paracetamol 500 mg. 1
tab. q4H as ordered by the physician
PTx
(Education or Health teaching)
ex: Instruct the patient on proper wound dressing.
PEd
Nursing interventions on the care plan should be:
• (1) ________ when they are written
• (2) ________ regularly at intervals
(1) Dated
(2) Reviewed
Implementation
D - ________
D - ________
D - ________
Doing
Delegating
Documenting
Putting the nursing care plan into action to achieve
the expected outcome
Implementation
Giving nursing care/carrying out the planned nursing activities
Implementation
Delegating the care to another health care team member
Implementation
Documenting and validating care
Continuing data collection
Implementation
Determining the client’s response to nursing interventions using the goals of care as criteria whether they were
- Met
- Partially Met
- Not Met
Evaluation
Goal Statement
• Will ambulate half the length of hallway w/ assistance 3x daily
Evaluative Statement
• Goal is __________. Patient refused to ambulate in the morning but walked to the bathroom once in the afternoon w/ the assistance of one nurse.
Goal partially met
Goal Statement
• Body temperature will decrease from 38.50C to 36.50C - 37.50C within 2 hrs. after administering TSB.
Evaluative Statement
• Goal is ________. Body temperature went down to 37.20C within 2 hours after TSB administration.
Goal met
