The Nursing process Flashcards
Phases of the Nursing process
A- Assessment D- Diagnosis P- PLanning I -Implementation E- Evaluation
Systematic and continuous collection, organization, validation,interpretation and documentation data.
ASSESSMENT
What are the types of Assessment?
- Initial
- Problem-focused
- Emergency
- Time-lapsed
During admission/ to establish a database
Initial
Ongoing process/ to monitor and/or identify a specific,new, or overlooked problems
Problem-focused
Emergency or crisis situations / to identify life-threatening problems
Emergency
Several months after initial assessment / to compare a client’s status over a period of time
Time-lapsed
Activities during assessment
- Data collection
- validaton of data
- organization of data
- documentation of data
Types of Data
Subjective (covert,symptoms)
Objective (overt,signs)
Felt and experienced by the patient
Subjective (covert,symptoms)
Detected by an observer
Objective (overt,signs)
Sources of data
- Primary- client
2. Secondary- family members, friends,health professionals, records
Methods of data collection
- Observation
- Interview
- Physical examination
Data are validated whether complete and accurate
Data verification
Nurse organizes and clusters the information together in orfer to identify areas of strenght and weaknesses.
Data organization
Assessment Models
- Gordon’s 11 functional health
- Orem’s self-care Model
- Roy’s adaptation Model
- Body system’s model -neuman
Translation of the information into nursing diagnosis
Data interpretation
Basis for determining the quality of care and should include appropriate data to support identified problems
Data documentation
Interpretation of assessment data and identification of the client’s strengths and problems
Diagnosis
Science and art of identifying problems or conditions
Diagnosis
Is a clinical judgement about individual,family or community responsea to actual or potential health problema/life processes
Nursing diagnosis
Standardized name, and problem statement
Diagnostic label
Relationship between a problem and its related or risk factors
Etiology
Types of nursing diagnosis
- Actual diagnosis
- Risk bursing diagnosis/ potential problem
- Possible nursing diagnosis
- Wellness Diagnosis
