Nursing process Flashcards
6 foundational concepts in nursing care
Nutrition Elimination Oxygenation Fluid and electrolyte balance Activity and mobility Rest and sleep
American Nurses Assoc (ANA)
Organization responsible for formulating generic standards of nursing practice
Subjective date
Data from patients regarding their Feelings, values and perspectives
Objective data
Diagnostic report, imaging,
nurses can Obtain objective data from 5 senses
Observations
Assessment in the nursing process
Collecting and organizing data
Diagnosis in the nursing process
Sometimes called analysis
Once data is collected and organized in assessment, the nurse synthesizes the data to identify patients actual or potential health problems that are amenable to some kind of nursing intervention
NANDA International
Maintains taxonomy of of approved nursing diagnoses
4 categories of nursing dx
Actual
Risk
Health promotion
Syndrome
Actual nursing dx:
How are the statements set up?
Diagnosis… r/t… AEB
As evidenced by
How are risk diagnoses statements set up?
Written as 2 part statements without s/sx.
Risk for… related to….
Health promotion diagnoses:
How are the statements written?
One part statement that include diagnostic label only.
Health promotion diagnoses begin with “readiness for” and do not include any related factors.
How are syndrome diagnoses written?
One part statement
And example of a syndrome diagnosis is “impaired environmental interpretation syndrome”
Maslow’ hierarchy of needs.
List from most immediate needs first.
Physiological Safety and security Love and belonging Self esteem Self actualization
Outcomes identification
Determine expected outcomes
Patient centered goals that are measurable.
Some broad categories of desired outcomes:
-optimal physiological function of all body systems - physical and psychosocial comfort - adequate mobility and maximal independence -effective coping and adaptation - comprehension of information
