The Nursing Process Flashcards
what are the characteristics of the nursing process
- cyclical
- patient centered
- focus on problem solving
- focus on decision making
- interpersonal and collaberative
- use of critical thinking
purpose of the nursing process
- gather data
- cluster data
- engage in critical thinking
- foster clinical reasoning
- make decisions
- plan care
- evaluate care
assessment involves
- collect data
- organize data
- validate data
- document data
nursing diagnosis involves
- analyzing data
- identify health problems, risks, and strenghts
- formulate diagnostic statements
planning involves
- prioritizing problems and diagnosis
- formulate goals and designed health outcomes
- identify nursing interventions
implementation involves
- reasses the patient
- determine the nurse need for assistance
- implement nursing interventions
- supervise delegated care
- document nursing activities
evaluation involves
- collecting data related to outcomes
- complete data with outcomes
- relate nursing actions to patient goals/outcomes
- draw conclusion about problem status
- continue, modify, or end the patients care plan
initial assesment
- explores the presenting problem
- identifies contributing factors
intitial assesment includes
- physical assesment
- health history
- psychosocial assesment
focused assesment
- gathers specific details about the presenting concern to either confirm or rule out abnormalities
time lapsed assesment
- to reevalute the patients status and identify whether the condition has improved, worsened, or stayed the same
emergency assesment
- to ensure the patient has a patient airway, is breahting, and has adwquate circulation
- to identify the primary cause of the problem
subjective data
what the patient says
objective data
what the nurse observes or collects from others
sources of data
- patient and family
- physical assesment
- the enviorment
- medical records and interprofessional team
- liturature
what are the 9 social determents of health
- Income and social status
- social support networks
- employment and working conditions
- physical environments
- education
- healthy child developments
- biological and genetic endowment
- health services
- personal health practices and coping skills
what are gordons functional health patterns
- health perception management
- nutritional metabolic
- elimination
- activity excersize
- sleep / rest
- cognitive perceptual
- self perception / self concept
- roles / relationships
- sexuality / reproduction
- coping / stress tolerance
- values / beleifs
Mazlows Hierarchy of Needs (top to bottom)
self-actualisation
esteem needs
social needs
saftey needs
physiological needs
self actualization includes
mortality, creativity, spontanetiy, problem solving, lack of prejudice, acceptance of facts
esteem includes
self esteem, confidence, achievement, respect of others, respect of others
social needs / love and belonging includes
friendship, family and sexual intimacy
saftey inculdes
security of body, employment, resources, morality, family, health
physiological needs include
breathing, food, water, homestasis, excretion
what are the 5 steps of the nursing process
Assessment
Nursing Diagnosis
Planning
Intervention
Evaluation
what are the three steps of formulating a nursing diagnosis
- Choose the NANDA label (actal, risk, wellness, syndrome)
- determine etiology (likely cause) “realted to …”
- list signs and symptoms
“as evidence by”
initial planning
- based on admission assesment
- directs patient care
ongoing planning
continually changing plans based on patient responce to care (assessment and evaluation)
discharge planning
anticipates and plans for the care needs when the patient moves through the health care system to home or to another care facility
SMART goals stand for
Specific
Measurable
Achievable
Relevant
Timely
short term goals ar emore common in
acute care
Independent nursing interventions
nurse can accomplish without an order form the physician or NP
dependent nursing interventions
initiated by the physicians orders
collaberative nursing interventions
nurse and another health care professional collaberate on interventions
- usually nurse completes them and the physician approves them
Direct care
- anything that involves working directly with the patient
indirect care
- communicates with HCP about the patients care
- delegating, supervising, evaluating the work of others
- planning and documenting care
evaluating of SMART goals
- Goal met
- goal partically met
- goal not met
