Nursing Process, Critical Thinking, Clinical Judgement, Evidence Informed Practice Flashcards
what are the 5 phases of the nursing process?
- Assessment
- Diagnosis
- Outcomes/Planning
- Implementation
- Evaluation
what occurs during the assessment phase?
- gathering data and compiling a health history
- collaboration among the client, the family, and other members of the health care team
- documentation
what occurs during the diagnosis phase?
- analyzing data
- identifying health problems and risks as well as strengths
- formulating diagnostic statements
- forming a clincial judgement about client and family
define actual diagnosis
Identifies an existing problem based on current signs & symptoms.
define risk diagnosis
Identifies a potential problem that may develop if not prevented.
define health promotion diagnosis
Identifies a patient’s motivation to improve health behaviors.
define wellness
Focuses on a client’s strengths and resources for continued well-being.
what occurs during the planning phase?
- Develop SMART goals
- Identify health outcomes
- Prioritize appropriate nursing interventions
- Coordinate necessary resources
- Prioritizing Nursing Diagnoses and Client Care
what are the characteristics of a SMART goal?
- Specific
- Measurable
- Achievable
- Relevant
- Time based
what occurs during the implementation phase?
- Reassessing the client
- Determining in what ways the nurse needs assistance
- Implementing the nursing interventions
- Supervising any delegated care
- Documenting all the nursing activities
define independant actions
nurse-initiatedq
Actions the nurse can perform autonomously based on assessment and nursing judgment
define dependant actions
physician initiated
Actions requiring a physician’s order but carried out by the nurse.
define collaborative actions
Actions requiring coordination with other healthcare professionals.
what occurs during the evaluation phase?
- The nurse reviews and measures whether the care goals were met
- Identifies any unintended outcomes
- Determines if any changes to the plan are required to accomplish any unmet goals
