week 3 nursing process Flashcards
what is the definition of the nursing process
framework to guide thinking
-critical thinking, decision making, diagnostic reasoning, problem solving, clinical judgment
what kind of process is the nursing process
cyclic
what is a nursing care plan
Identifies client problems in need of nursing care
Predicts outcomes sensitive to nursing care
Lists intervention that will result in expected outcomes
what is the purpose of the nursing care plan
communicate planned care to health care team
Ensure continuity of care
what is the definition of assessment
the process of gathering information about a client’s health status to identify concerns and needs than can be treated or managed by nursing care.
what does assessment require and must use
critical thinking
reasoning, analyzing and translation
what is the purpose of the assessment
consider the situation
what are the type of assessment
initial
focused
emergency
onling
how to collect data through assessment
active listening
active processing
observing
translating
what is active listening g
listen to client and help clarify and elaborate. Listen to meaning behind what is being said
what is active processing
analyze and interpret info (How does this info fit with what I know about a disease?)
what is translating in assessment
translate what client says into meaningful, succinct statement
Group data into meaningful patterns (ex, restless, rapid resp., cyanotic)
what is the reasoning of collecting data
actively process info to make mental connections of the data to diseases, health patterns
what is validating of collecting data
confirming accuracy of info using another source
what are functional health patterns in assessment
refers to the positive and negative behaviors a person uses to interact with the environment and maintain health.
health maintenance patter is
clients personal view of health and behaviors associated with the quest to be healthy
what is the nutritional metabolic pattern
dietary habits in relations to metabolic need
what is the elimination pattern
bowel and bladder habits
what is the activity exercise pattern
ability to be active and level of activity person chooses. persons physical capability for self care
what is the sleep-rest pattern
pattern of sleep and rest
what is the cognitive perceptual pattern
senstation, perception, and cognition.
memory, language, vision, hearing, orientation, senses
what is self perception- self concept pattern
how person views self.
role relationship pattern
relationships with others,
sexuality -reproductive pattern
present from both to death. expression of sexuality varies
what is coping-stress tolerance pattern
stress is a part of everyones life
management of stress
what is value belief pattern
philosophical position that guides a persons choices in life
what is so important with assessment
document
what are the componenet of the NANDA-1 nursing DX
label defintion defining characterisitics related factors risk factors
what are the types of nursing diagnosis
actual
risk for
wellnesss
collaborative
what is an actual diagnosis
current problem
Can identify S/S (defining characteristics)
Ask: Are there S/S that indicate a problem exists?
what is a risk for diagnosis
problem that may develop
plan of care to PREVENT problem
what is a wellness diagnosis
a desire by person, family, community to move to higher stat of being
what is a collaborative diagnosis
interventions from different healthcare team members may
how many parts are in the actual nursing diagnosis
3
what does P stand for
problem followed by the words related to
what does E stand for
etiology followed by the words as manifested by
what does S stand for
sign and symptoms
how many parts is a risk for diagnosis
2
what parts are in the risk diagnosis
P
E
what are some sources of diagnostic effort
errors in collecting data
cue clustering
interpretation
under or over diagnosing
what is ongoing planning
as clients condition changes need to modify plan
what is a discharge plan
prepatation for moving from one level of care to another
what is collaborative planning
planning with other healthcare professionals
what is MART
measurable
achievable
realistic
time frame
what is NIC
nursing intervention classificaiton system
