Test 1 section 2 Flashcards
is a critical thinking process the professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
nursing process
nursing process steps
Assessment Diagnosis Planning Implantation Evaluation
gathering, critically examining, and analyzing data
assessment
identifying client response to health problems
Formulating appropriate nursing diagnosis
Nursing diagnosis
Determining priorities
establishing goals and expected outcomes
Planning
Taking appropriate actions
implementation
Evaluating effectiveness
Evaluation
client/family
primary source
physical exam, nursing history, team members, lab reports, diagnostic test
secondary source
from the client
symptoms
subjective
observable data
sign
objective
Nursing diagnosis is composed of 3 parts
Problem statement
Etiology
Defining characteristics
the clients response to a problem
problem statement
whats causing/ contributing to the clients problem
etiology
whats the evidence of the problem
Defining characteristics