Nursing Process Flashcards
What are the DOH that the nursing process assessment uses?
personal resources(god) Professional Resources Social Resources Environmental factors Transitions
What is the nursing process?
systematic, rational, individualized nursing care, with method of planning
What do you do during assessment?
collect and interpret data of clinical info/data
Where can assessment data be acquired?
head to toe assessment other HC Family Pt Med records
What are two steps of Assessment?
data collection
data clustering
What is a nursing diagnosis?
clinical judgement about an individual, family or communities response to actual or potential life processess within the domain of nursing
Formulation of a nursing diagnoses requires? 2
Clinical judgement
critical thinking
What should a nurse utilize when making a nursing diagnoses?
scientific/personal knowledge, experience, intuition
What is a one part Nrs dx?
wellness
readiness for enhanced nutrition
How to make a nursing dx? an actual one
actual problem r/t causative factors m/b signs/symtoms
What does planning include?
mutually defined goals, that are achievable and measurable
it involves priority setting, nursing care plan, mutual goals
What is a nursing goal?
statements of expected outcomes based on nrs DX.
What are the guidlines for goals?
based on pt bhvr
based on nurse dx
something that is observable/measurable
timely
What does the goal acronym TRAMP stand for?
Time Realistic achievable measurable pt centred
What does implementation include?
interventions based on PHC principles, partnerships
planned activities
ongoing assessment of pt responses
