nursing process Flashcards
o Systematic, rational method of planning and
providing individualized nursing care
Nursing process
Phases of the Nursing Process
o Assessing
o Diagnosing
o Planning
o Implementing
o Evaluating
Planning the interview and setting
Time
Place
Seating arrangement
Distance
Language
Cephalocaudal approach
- Head-to-toe progression
Conceptual Models and Frameworks
Gordon’s functional health pattern framework
o Orem’s self-care model
o Roy’s adaptation model
Assist clients to identify and explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes
Wellness Models
4 types of assessment
o Initial nursing assessment
o Problem-focused assessment
o Emergency assessment
o Time-lapsed reassessment
DATA COLLECTION METHODS
Observing
Interviewing
Examining
Cephalocaudal approach
Head-to-toe progression
Assist clients to identify and explore lifestyle
habits and health behaviors, beliefs, values, and
attitudes
Wellness Models
Nonnursing Models
Body systems model
Maslow’s Hierarchy of Needs
Developmental theories
Developmental theories
▪ Havighurst’s age periods and
developmental tasks
▪ Freud’s five stages of development
▪ Erikson’s eight stages of development
Piaget’s phases of cognitive
development
▪ Kohlberg’s stages of moral development
The act of “double-checking,” verifying data to
confirm it is accurate and factual
Validation
Nurses use critical thinking skills to interpret assessment
data and identify client strengths and problems.
DIAGNOSING
A statement or conclusion regarding the nature of
a phenomenon
- Diagnosis
STATUS OF THE NURSING DIAGNOSES
o Problem presents at the time of assessment.
o Presence of associated signs and symptoms
- Actual nursing diagnosis
STATUS OF THE NURSING DIAGNOSES
o Cluster of nursing diagnoses that have similar
interventions
Syndrome diagnosis
STATUS OF THE NURSING DIAGNOSES
o Preparedness to implement behaviors to improve
their health condition
o Example: Readiness for Enhanced Nutrition
Health promotion diagnosis
STATUS OF THE NURSING DIAGNOSES
o Problem does not exist.
o Presence of risk factors
Risk nursing diagnosis
o Cluster of nursing diagnoses that have similar
interventions
Syndrome diagnosis
o Separation into components (deductive
reasoning)
- Analysis
o Putting together of parts into whole (inductive
reasoning)
- Synthesis
THE DIAGNOSTIC PROCESS
- Critical thinking
- Analysis
- Synthesis
o Problem (P)
o Etiology (E)
o Joined by the words “related to”
Basic Two-Part Statements
▪ Problem (P)
▪ Etiology (E)
▪ Signs and symptoms (S)
Basic Three-Part Statements
o PES format
o Health promotion diagnoses beginning with
Readiness for Enhanced
o Seven syndrome diagnoses
One-Part Statements
DEVELOPING NURSING CARE PLANS
A strategy for action that exists in nurse’s mind
Informal nursing care plan
DEVELOPING NURSING CARE PLANS
A formal plan that specifies actions for a group of
clients with common needs
Standardized care plan
DEVELOPING NURSING CARE PLANS
Written or computerized guide
Formal nursing care plan
DEVELOPING NURSING CARE PLANS
Tailored to meet the unique needs of a specific
client
Individualized care plan
Types of Nursing Interventions
o Activities nurses are licensed to initiate (i.e.,
physical care, ongoing assessment)
Independent interventions
Types of Nursing Interventions
Activities carried out under primary care
provider’s orders or supervision, or according to
specified routines
Dependent interventions
Types of Nursing Interventions
o Actions nurse carries out in collaboration with
other health team members
o Reflect overlapping responsibilities of healthcare
team
Collaborative interventions**
Groups information into three categories
o Problems
o Interventions
o Evaluation
NURSING CARE PLAN
o Written for each client
Traditional care plans
NURSING CARE PLAN
o Based on institutions standards of practice
Standardized care plans
Concise method of organizing and recording data
* Series of cards kept in a portable index file or on
computer-generated form
* Information quickly accessible
KARDEXES
Skin Assessment Record
Such as
the Braden Assessment
Body temperature, pulse, respiratory rate, blood
pressure, weight, other significant clinical data
Graphic Record
o Initial nursing assessment for each client
The Joint Commission
▪ History
▪ Physical examination
▪ Performed and documented within 24
hours of admission
aka covert data
subjective data
aka overt data
objective data
Cues
▪ Subjective, objective data that can be
directly observed by the nurse
▪ Nurse’s interpretation based on cues
Inferences
The first taxonomy was
alphabetical.
The first taxonomy was alphabetical.
* Later version based on
“human response patterns”
- Taxonomy II has three levels.
o Domains
0 Classes
o Nursing diagnoses
o Deliberate, systematic, problem-solving phase of
nursing process
planning
