Nursing Process Flashcards
nursing process
a process nurses use to evaluate and select the best actions to meet desired goals
critical thinking skills needed for clinical decisions
- reasoning
- intellect
- creativity
- inquiry
- reflection
- intuition
behaviors to improve critical thinking skills
- intellect: build clinical knowledge and skills; cluster cues r/t a pattern
- creativity: brainstorming; what other approaches might facilitate success; finding solutions to unique problems
- inquiry: ask questions about nursing practice; make changes in practice based on evidence and innovative ways of doing things better
5 phases of the nursing process
- assessment
- nursing diagnosis
- planning
- implementation
- evaluation
assessment (nursing process)
gathering info to determine what the problem is using patient’s past medical hx, nursing assessment/vitals, or diagnostic studies
subjective
patient shares/says/reports
“pain level/nausea/blurred vision”
objective
data you can perceive and often measureable
“bowel sounds are hyperactive/skin is warm and dry”
nursing diagnosis
stating the specific problem that needs to be addressed
-provides a basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable
why do we write a nursing diagnosis?
helps distinguish the nurse’s focus from the physician’s focus
Focus of the nursing diagnosis
human responses
Focus of the medical diagnosis
disease process/pathophysiology
“ineffective airway clearance”
nursing diagnosis
“pneumonia”
medical diagnosis
how to write a nursing diagnosis
- what is the problem? (dx)
- what is causing the problem? (related to…)
- defining characteristics of the problem…(as manifested by…)
Two types of nursing diagnosis
- risk for
- actual
