Nursing Process Flashcards
5 steps of nursing process
- Assessment
- Diagnosis
- Plan
- Implementation
- Evaluation
8 basic elements of health history
- Age
- Sex
- Developmental state
- Health state
- Health care system factors
- Sociocultural orientation
- Family system factors
- Patterns of living
3 categories of developmental stage
Cognitive (recent/remote memory and attention span), physical, psychosocial
General structure of self care demand
INABILITY TO (or decreased ability to/inefficient…) description of clinical problem RELATED TO self care related to the reason for the clinical problem
Ex: inability to self administer Fragmin injections related to a lack of knowledge and skills
Types if objective data
Inspection, auscultation, palpation, percussion
Primary source of info
Patient
Secondary sources of info
Family, pt chart, other health team members, literature
Clustering data involves
Recognizing clinical cues and making inferences (giving meaning to/interpreting data) and collecting/identifying data that supports preliminary conclusion
When to validate data
When unexpected or odd, differs from previous statements, conflicting data
Question to validate data!!!
If i understand correctly… (polite and repeats what you heard)
4 types of assessments during nursing process
- Initial
- Problem-focused
- Emergency
- Time-lapsed
Always ask 3 questions when analyzing data piece
- How does it compare with norm
- How does it compare with baseline
- What does research/textbook say about its meaning
Action demand consists of synthesis statement and actions to be taken :
Increase in the knowledge and skill related to self administration of Fragmin in a 36 yr old suffering from a DVT by implementing a teaching plan before discharge
Synthesis example statement
Verb + universal need + in a + age + sex of pt + story that makes it particular
Ex : decrease risk of injury in a 72 yo gentlemen who is blind
Three types of planning
- Initial
- Ongoing
- Discharge
