nursing process Flashcards
organized and delivery of nursing care has to be
Dynamic
Continuous process
Use crintical thinking to:
make judgements and take actions based on reason
assists with responding to patient needs
as a nurse you need to be able to
identify
diagnose
treat human responses to health and wellness
nursing process promotes;
individualized nursing care
nursing process differentiates nursing practice
from other health care professionals
patients can be active participants
nursing process 5 components
assess diagnose plan implement evaluate
assess to
gather information about the clients condition
diagnose to
identify the clients problems
plan to
set goals of care and desired outcomes and identify appropriate nursing actions
implement to
perform the nursing actions identified in planning
evaluate to
determine if goals met and outcomes are achieved
critical thinking approach to assessment
involves collecting information from the patient and from secondary sources like family members, along with interpreting and validating the information to form a complete database
two stages of assessment
collection and verification of data
analysis of data
four components of assessment
knowledge
standards
attitudes
experience
knowledge of assessment
underlying disease process
normal growth and development
normal physiology and pychology
health promotion
assessment skills
communication skills
standards of assessment
ANA scope and standards of nursing process
specialty standards of practice
intellectual standards of measurement
attitude of assessment
perseverance
fairness
integrity
confidence
creativity
experience of assessment
pervious patient care experience
validation of assessment findings
observation of assessment techniques
Types of assessments
patient-centered interview during a nursing health history
physical exam
periodic assessments made during rounding or administering care
sources of data
patient
family and significant others
health care team
medical records
scientific literature
patient data types
interview
observation
physical examination
(the best source of information)
in order to obtain info from family you need to:
obtain patients agreement first
types of data
subjective
objective
subjective data
feelings,
perceptions,
self-report (verbal descriptions)
only patient can provide this information