Nursing Process chp3-7 EXAM 1 Flashcards
The Nursing Process steps:
- Assessment
- Diagnosis
- Planning
- Interventions
- Implementation
Assessment
gathering info related to the physical, mental, spiritual, socioeconomic, and cultural status.
-1st step in nursing process
data is:
observed, measurable and revealed to the nurse in multiple ways
types of assessment:
- Initial- on admission or start of shift. give u baseline
- Ongoing- reassement/prn assessment
- Comprehensive- physical exam, Nursing interview (cultural/religious belief) hollistic info, values, beliefs
- Focused Assessment- initial, ongoing
what is the best source of information you can ever obtain?
Your Assessment
Sequence of Care Plan Development
- Nursing Diagnosis- response to medical diagnosis
- Related to- define medical diagnosis, describe, NOT MEDICAL DIAGNOSIS
- As Manifested by- assessment info that supports diagnosis
- Goals
- Interventions
- Best Practice- best evidence base that supports intervention
- Evaluation
Nursing Diagnosis
2 in nursing process
- reasoning process used in interpreting assessment dat.
- provides basis for positive outcomes
- primary focus: partnership with pt
- describes response to actual or potential problems
Nursing Diagnosis clinical/physical response
body image disturbance/ risk factor ineffective airway clearance acute pain self care deficit altered nutrition: greater than body
diagnostic reasoning
the thinking process that enables you to make sense of it all.
- Depends on: critical thinking
- analyze
- interpret data, draw conclusions, verify problems with pt
- record the information
Prioritizing problems
- Low priority- problems that require minimal supportive nursing intervention
- Medium Priority- problems that don’t pose a direct threat to life
- High Priority- problems that are life threatening or that could have a destructive effect on the pt
a diagnostic statement consists of:
a problem and an etiology.. linked by a connective phrase.
how to format a diagnostic statement: (3)
- basic 1-part statement- omitting etiology from certain kinds of diagnostic statements
- basic 2-part statement- Problem R/T etiology
- basic 3-part statement- Problem R/T etiology as manifested signs or symptoms
Planning
#3 in Nursing process - need accurate, complete assessment data and correctly identified and prioritized nursing diagnosis.
Interventions
#4 in Nursing Process - actions based on clinical judgement and nursing knowledge, that nurses perform to achieve patient outcomes
reports developed by scientists using a grading system to review studies and ranks the strength of their evidence
Evidence Based Practice Center (EPC)
Statements developed by systematic review of evidence and an assessment of the benefits and harms of care options
Clinical Practice Guidelines
Evaluation
Last step in Nursing Process
- planned, ongoing, systematic activity in which ou will make judgements about:
- pts progress toward goal
- effectiveness of nursing care plan
- quality of nursing care in the healthcare setting
encompass each step of the nursing process
central source of info needed to guide holistic, goal oriented care to address each pt’s unique needs
Patient care plans
Patient care plans:
- ensure care is complete
- provide continuity of care
- promote efficient use of nursing efforts
- provide a guide for assessments and charting
- meet the requirements of accrediting agencies
