WEEK 3- NURSING AS A SCIENCE Flashcards
The cornerstone of the nursing profession
NURSING PROCESS
Originated the term NURSING PROCESS in 1955
LYDIA HALL
LYDIA HALL had three steps in nursing process, what are they?
- note observation
- ministration of care
- validation
she came up with the behavioral system models and introduced three steps of nursing process
DOROTHY JOHNSON
what three steps of nursing process did dorothy johnson introduce?
- assessment
- decision
- nursing action
she introduced the nursing process,
IDA JEAN ORLANDO
what are IDA JEAN ORLANDO’S three nursing process?
- client’s behavior
- nurse’s reaction
- nurse’s action
who was in charge of identifying the SIX STEPS OF NURSING PROCESS?
ANA- AMERICAN NURSES ASSOCIATION
what are the six steps of the nursing process according to ANA?
- assessment
- diagnosis
- outcome identification
- planning
- implementation
- evaluation
what are the basic concepts of the nursing process?
- nursing
- person
- environment
- health
is defined as a systematic, continuous and dynamic method of providing care to clients. It compromises series of sequential phases built upon the preceding step. Each phase logically leads to the next
NURSING PROCESS (NP)
What are some characteristics of the nursing process?
- dynamic and cyclic
- patient centered
- goal directed
- flexible
- problem oriented
- cognitive
- action oriented
- interpersonal
- holistic
- systematic
5 steps in nursing process
- assessment
- nursing diagnosis
- planning
- implementing
- evaluating
this is also known as gathering data
assessment
identifying the problem and formulating a nursing diagnosis
analyzing
writing a care plan to meet goals
PLANNING
carrying out plan
IMPLEMENTING
collect obj data, determine extent to which goals were achieved, revise plan as needed.
EVALUATION
deliberate systemic collection of data to determine client current and past health status
ASSESSMENT
what are the two types of assessment?
comprehensive assessment
focused assessment
examines the patient’s overall health status
comprehensive assessment
frequently performed on an on going basis to monitor and evaluate the patient’s progress, interventions, and response to treatments
FOCUSED ASSESSMENT
components of assessment
- collection of data
- verification of data
- organization of data
- recording of data
purposes of assessment
-establish database
these are client’s perception about their health problem e.g. pain
SUBJECTIVE DATA
these data are observable and measurable by data collector e.g. vital signs
OBJECTIVE DATA
source of data is client themself
PRIMARY SOURCE
source of data is family and significant others, healthcare team members, medical records, other records, literature review, nurses experience
SECONDARY SOURCES
It is an organized conversation with the client or family member to obtain the current health information regarding patient
INTERVIEW TECHNIQUE
A ____ is defined as “a clinical judgement about an individual, family, or community response’s to actual and potential health problems/ life processes. ____ provide the basis for selection of nursing intervention to achieve outcomes for which the nurse is accountable.
NURSING DIAGNOSIS, (NANDA,2009)
AN ACTION: the process of analyzing assessment data
nursing diagnosis
_____ is a label that describes the patient’s response to an actual potential health problem
Nursing diagnosis
describes a disease or pathology,
medical diagnosis
describes patient’s response to a health problem
NURSING DIAGNOSIS
patient has problem, judgement about the client response to a health problem that is present at a time of nursing assessment
actual nursing diagnosis
patient is at risk for developing the problem, “risk for or is at risk for”. Clinical judgement that a client is more vulnerable to develop the problem than others in the same or similar situation
RISK Nursing Diagnosis
CLINICAL JUDGEMENT about an individual, group or community in transition from a specific level of wellness to a higher level of wellness. patient functioning effectively but desires higher level of wellness
WELLNESS DIAGNOSES
describe a suspected problem for which current and available data are insufficient to validate the problem
POSSIBLE NURSING DIAGNOSIS
component of nursing diagnosis
- problem statement
- etiology
- defining characteristics
describe the client health problem or response for which nursing therapy is given clearly and concisely in a few words (impaired, decreased, ineffective are some of the words used)
PROBLEM STATEMENT
this component identifies one or more probably causes of health problem. It help the nurse to give individualized patient care (uses words like “related to”
ETIOLOGY (Related Factors & Risk Factors)
these are the clusters of signs and symptoms that indicate the presence of a particular diagnostic label (manifested by…)
DEFINING CHARACTERISTICS
____ is a category of nursing behavior in which client centered goals and expected outcomes are established and nursing interventions are selected to achieve the goals and outcomes of care
PLANNING
what are the phases of planning?
- initial
- ongoing
- discharge
____ is the ordering of nursing diagnosis and patient problem using determinations of urgency and or importance
PRIORITY SETTING
what are the classification of priorities
high, intermediate, low
it reflects a patients highest possible level of wellness and independence in function, it can be short term or long term
GOAL
is a measurable change in a patients status that is expected to occur in response to nursing care
EXPECTED OUTCOME
What does MACROS stand for in goals
M- measurable and observable A-achievable and tie limited C- client centered R- realistic O- outcome written S- short
actions initiated by nurse that do not require direction or an order
NURSE INITATED INTERVENTION
actions implemented in a collaborative manner
COLLABORATIVE INTERVENTION
actions that require an order
PHYSICIAN INITIATED INTERVENTION
the judgement of the effectiveness of nursing care to meet client goals; in this phase nurse compare the client behavioral responses with predetermined client goals and outcome
EVALUATION
hand over information about nursing care of clients to nurses
NURSING HANDOVER
appreciation that is sometimes offered by clients
PATIENT SATISFACTION
reflect on own experiences both socially with other friends
REFLECTION
evaluates the care given against the set goals
REVIEWING THE PLAN
formal guideline for directing nursing staff to provide client care
NURSING CARE PLAN
