Overview of Nursing Process Flashcards
“The very elements of nursing are all but
unknown”
- FLORENCE NIGHTINGALE 1859
HEALTH ASSESSMENT
the diagnosis and treatment of
human responses to health and illness
Nursing
5 steps of the Nursing Process (ADPIE)
- ASSESSMENT
- DIAGNOSIS
- PLANNING
- INTERVENTION
- EVALUATION
Systematic collection of data The most important step Sets the tone for the rest of the process, and the rest of the process flows from it Identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process.
Assessment
Clinical judgment concerning a human response to health conditions / life processes, or vulnerability for that response by an individual, family or community that the nurse is licensed and competent to treat
Diagnosis
identifies an
occurring health problem for your
patient.
actual nursing diagnosis
identifies a high-risk health problem that most likely will occur unless preventive measures are take
potential nursing diagnosis
is one that
needs further data to support it
possible nursing diagnosis
Desired outcomes
Appropriate interventions
Involves setting goals and outcomes
Planning
objective behavior or response that
you expect a patient to achieve over a longer
period, usually over several days, weeks or
months
Long Term Goals
objective behavior or response that
you expect the patient to achieve in short
time usually few hours or less than a week
Short Term Goals
Planning should be SMART
✓ Specific ✓ Measurable ✓ Attainable ✓ Realistic ✓ Time-bound
Defined as any treatment based on
clinical judgment and knowledge that a
nurse performs to enhance patient
outcomes
Intervention
Action that the nurse initiates without
supervision or direction from others
Independent
Actions that require an order from a
health care provider
Dependent
Interdependent interventions
Therapies that require the combined
Collaborative
Final step of the nursing process Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process
Evaluation
is the deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and coping patterns.
Assessment
Involves collection of subjective data about the client’s perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices (which includes information related to the client’s overall function) as well as objective data gathered during a step by-step physical examination.
Initial Comprehensive Assessment
Consists of data collection that occurs
after the comprehensive database is
established. This consists of a mini overview of the client’s body systems
and holistic health patterns as a followup on health status.
Ongoing or Partial Assessment
It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern
Focused or Problem-Oriented Assessment
a very
rapid assessment performed in lifethreatening situations. In such
situations (choking, cardiac arrest,
drowning), an immediate assessment is
needed to provide prompt treatment.a very
rapid assessment performed in lifethreatening situations. In such
situations (choking, cardiac arrest,
drowning), an immediate assessment is
needed to provide prompt treatment.
Emergency Assessment
performs a focused assessment, and
then incorporates assessment findings
with a multidisciplinary team to
develop a comprehensive plan of care
Acute Care Nurse
need enhanced assessment skills to
safely assess critically ill clients who are
outside the structured intensive care
environment (Coombs & Moorse, 2002).
Critical Care Outreach Nurses
assess and screen clients to determine
the need for physician referrals.
Ambulatory Care Nurses
make independent nursing diagnoses
and referrals for collaborative problems
as needed.
Home Health Nurses
assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families.
Public Health Nurses
