the nursing process Flashcards
what is the nursing process?
series of organized steps designed to provide excellent care, process with reason
what are the 5 components to the nursing process? (think ADPIE)
- assess
- diagnose
- plan
- implement
- evaluate
what is part of the assess component of the nursing process?
gathering information about the client’s condition (subjective and objective)… relies on critical thinking skills… should be systematic and holistic… develop a base of data
what are the different methods during the assessment phase?
labs, interview, observation, interpretation of the data
what is primary data?
data directly from the pt
what is secondary data?
data from all other sources than the pt
who can provide secondary data?
family, healthcare team, medical records
does subjective data have signs or symptoms?
symptoms
does objective data have signs or symptoms?
signs
what is a cue?
the information the nurse obtains through their senses
what is an interence?
ones interpretation of the cues (what you think is happening)
what is part of the diagnose component of the nursing process?
identifying the clients problems and considering how the client experiences their problems, NOT A MEDICAL DIAGNOSIS… knowing how the diagnosis affects the client
then generating a problem statement
what is a problem statement derived from?
“whats going on with the pt”
derived during the assessment and reflecting on how the pt responds to the disease process
what does identifying the problem mean? how does it differ from a medical diagnosis?
identifying the best way to help the pt and how you can contribute to their care, not a medical diagnosis bc it is not the disease, but how you can cater the care yo help the pt
what is NANDA-I?
North American Nursing Diagnosis Organization International
what does NANDA-I provide?
system used to state the priority problem with a pt, more than 200 diagnoses
what are the 3 types of nursing diagnoses?
actual
risk statment
wellness
what is the “actual” diagnosis?
identifies the problem happening with the pt
what is the “potential risk” statement?
identifies something that puts the pt at higher risk due to their situation, hasnt occurred yet
what is the “wellness” diagnosis?
identifies when things are going well with the pt, opportunity to enhance their wellness
what is the priority problem?
the hypothesis, problem statement
what is the primary diagnosis?
an issue that if not managed will deter progress and have negative outcomes with the pt
what is a non-primary diagnosis?
treatment that can be delayed without compromising pt status
least important
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/ \ what is the ?
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/ ? \ most important
physiological
least important ?
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/ \
/ \
/ \ most important
self-actualization
least important
/ ? \
/ \ what is the ?
/ \
/ \ most important
esteem
least important
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/ ? \ what is the ?
/ \
/ \ most important
love/belonging
least important
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/ \ what is the ?
/ ? \
/ \ most important
safety
what are the 5 needs that are most important for pt care?
physiological, safety, love/belonging, esteem, self-actualization
what is supportive data?
information that validates the problem statement/hypothesis… consists of evidence/assessment findings and contributing factors
what is part of the plan component of the nursing process?
answers the question… “what are we going to do?”… sets goals for the pt
what are the 3 components to the plan phase?
- setting pt centred goals and objectives
- determining the outcomes
- setting appropriate nursing interventions
what are the expected criteria for a plan?
SMART…
s - specific
m - measurable
a - attainable
r - relevant
t - time based
what is part of the implement component of the nursing process?
performing nursing actions identified in the planning phase
what are dependant nursing interventions?
require orders from a healthcare professional to implement
what are independent nursing interventions?
no order is needed from another healthcare professional
what are collaborative interventions?
require a combined knowledge, skill, and expertise from numerous healthcare providers
what is part of the evaluate component of the nursing process?
determining if the goals were met and the outcomes acheived
what are the 2 components of an evaluation?
an examination of a condition and judgment of the change has occured
