The Nursing Process Flashcards
What is the definition of the Nursing Process?
A decision making method used to identify & treat the responses of individuals or groups that alters their health.
What is the guiding process and primary component of the Nursing Process?
Critical-Thinking
What are the 5 aspects of the Nursing Process?
1.) Assessment
2.) Diagnosis
3.) Planning
4.) Implementation
5.) Evaluation
{ADPIE}
What is critical-thinking?
The art of thinking about your thinking while you are thinking in order to make your thinking better, more clear, more accurate, or more defensible.
It is a combination of reasoned thinking, openness to alternatives, an ability to reflect, & desire to seek truth.
What is Assessment?
Is the systematic gathering of information related to the physical to the physical, mental, spiritual, socioeconomic & cultural status of an individual, group, or community
As a nurse, you are the only one in charge of assessing your patient.
What does the Assessment phase include?
- Collecting data
- Using a systematic & ongoing process
- Categorizing data
- Recording data
Assessment: What is the difference between Subjective Data vs Objective Data?
- Subjective Data is what the patient says or complains about. An example would be a patient saying, “my head hurts”. YOU CAN’T SEE SUBJECTIVE DATA.
- Objective Data is the factual and measurable data. An example would be a patient vomiting. YOU CAN SEE OBJECTIVE DATA.
What is the difference between Medical Assessment vs Nursing Assessment?
Medical Assessment: focuses on disease and pathology.
Nursing Assessment: focuses on the client’s responses to illness
Different Types of Assessment:
Comprehensive: Consists of a complete nursing history and physical examination; contains subjective and objective data.
Focused: focuses on a particular topic, body part or functional ability rather than overall health status.
Assessment for ADLS:
- Mobility - does the client require devices (canes, crutches, walker, wheelchair) for support?
- Transfer - can the client get in and out of bed and in and out of a chair w/o assistance?
- Bathing - can the client perform a sponge bath, tub bath, or shower bath with no help?
- Dressing - can the client get all necessary clothing from drawers and closest and get completely dressed w/o help?
- Feeding - can the client feed self w/o assistance?
- Toileting - can the patient go to the bathroom, use the toilet, clean self, and rearrange clothing w/o help?
- Continence - does the patient independently control urination and bowel movement.
When validating data:
- subjective/objective data do not agree or make sense
- client’s statements differ at different times in the interview
- data are far outside normal range
- factors are present that interfere with accurate measurement.
When Documenting data:
- Document as soon as possible
- Write legibly w/o using unapproved acronyms
- avoid using inferences (“just the facts”)
- Use the patient’s own words in “Quotations”
- Record only pertinent, important, and relevant data or “pertinent negatives”
In the Nursing Process, what is diagnosis?
Using critical-thinking skills to identify patterns in the data and draw conclusions about the client’s health status.
What does diagnosis include?
- Strengths
- Problems
- Factors contributing to the problems
What is the difference between medical diagnosis and nursing diagnosis?
Medical: Describes a disease, illness, or injury.
Nursing: A statement of client health status that nurses can identify, prevent, or treat.
