NURSING PROCESS Flashcards
deliberative, systematic phase of the
nursing process that involves decision
making and problem solving.
planning
Refers to the client’s assessment data and
diagnostic statements for direction in
formulating client goals and designing the
nursing interventions required to present,
reduce or eliminate the client’s health
problems ; nurse’s responsibility
begins with the first client contact
and continuous until Nurse-Client
relationship ends, usually, when the client is
discharged from the health agency
planning
The nurse performs the admission
assessment usually develops the initial
comprehensive plan of care.
initial planning
The nurse has the benefit of seeing the client’s
body language and can gather intuitive kinds
of information that are not available solely
from the
written database
• Occurs at the beginning of a shift as the
nurse plans the care to be given that day
• All nurses who work with the client do
ongoing planning.
ongoing planning
→ To determine whether the client’s health
status has changed
→ To set priorities for the client’s care during
the shift
→ To decide which problems to focus on
during the shift
→ To coordinate the nurse’s activities so that
more than one problem can be addressed
at each client contact
purposes of ongoing planning
process of anticipating and planning
for needs after discharge, is crucial part of
a comprehensive health care plan and
should be addressed in each client’s care
plan ; begins at first client contact
discharge planning
process of establishing
a preferential sequencing for addressing
nursing diagnosis and intervention
setting priorities
In Maslow’s Hierarchy of Needs,
the physiologic needs of a person such
as air, food, and water, are basic needs
to life and receive _ priority
highest
what are the factors to consider when assigning priorities
client’s health values and beliefs
client’s priorities
resources available to the nurse and client
urgency of the health problem
medical treatment plan
Is a desired outcome or change in client
behavior
goal
More specific, measurable criteria used to
evaluate whether goal has been met
expected outcome
a comprehensive taxonomy of patient
outcomes influenced by nursing care.
nursing outcomes classification (NOC)
is required in all phases of the Nursing
Process.
standardized or common nursing language
Goals that can happen quickly
short term goals
Goals that take a long time to achieve
long term goals
Goals and outcomes are derived from the
client’s nursing diagnoses – primarily formt
he ; contains the unhealthy response, what should change
diagnostic label
is the client, any
part of the client, or some attribute of
the client, such as the client’s pulse or
urinary output
subject
specifies an action the client is
to perform
verb
may be added to
the verb to explain the circumstances under
which the behavior is to be performed ; what, where, when, or how
condition or modifier
indicates the standard by
which a performance is evaluated or the
level at which the client will perform the
specified behavior ; speed, accuracy, distance, quality
criterion of desired performance
The establish a time-achievement criterion,
the nurse needs to ask
how long
To establish accuracy criterion, the nurse
asks
how well
Write goals and outcomes in terms of __ not nurse activitie
client responses
Make sure that each goal is derived from
only __ nursing diagnosis.
one
Nursing process is action oriented, client
centered and outcome directed ; action phase in which
the nurse performs the nursing intervention ; doing and documenting
implementation