x 104, 1, The Nursing Process Flashcards
ANA stated in 2003
”..nurses are responsible for a unique dimension of healthcare…”
Elements of Prof Nursing
- provide caring relationship that fosters health and healing
- attn to range of human experiences and responses to health/illness within physical and social env
- use objective data w knowledge gained from patient
- Application of scientific knowledge to process of Dx and Tx thru use of judgement and critical thinking
- advancement of prof nursing knowledge through PD
- influence of social and public policy to promote social justice
WHen was the Nursing Process legitimized?
1973 when ANA Congress for Nursing Practice developed Standards of Practice to guide nursing performance
What year was Dx added to nursing process?
1974
Assessment, Dx, Planning, Implementation, Eval
The Nursing Process steps
ADPIE
- Assessment
- Dx
- Outcome ID and Planning
- Implementation
- Evaluation
What is the purpose of the nursing process
to provide a framework for nursing care of the patient in any envt.
Characteristics of the Nursing Process
- universally applicable
- systematic
- cyclical and dynamic
- patient centered, interpersonal, collab
- goal oriented
- problem solving process
Trend in Nursing Process
- toward standardization and computerization
- computer driven data bases allow nurses to plan and document
- critical pathways target desired outcome
Assessment
ANA Standard 1
- collection of pt centered data to be used as basis for identifying pt needs.
- ongoing process
Assessment Data
Data Collection:
-interview, observe, health hist, phys exam, ss, labs, reports. Subjective vs Objective
- Variations of data: physiological variations among populations
- Variation of approaches: style of convo, persona space, culture, age, energy level, cognition, phys state.
Common Assessment problems
- using inappropriate or inadequate assessment tools
- omitting data
- failure to update the initial assessment
Diagnosis
ANA Standard 2
-ID and prioritization of pt problems based on analysis of a comprehensive assessment and labeled as nursing dx.
Purpose of Dx
- to analyze/synthesize data to ID patients strengths and weaknesses
- make nursing judgement that ids patients response to health probs that fall within the scope of nursing practice.
Dx: Data Cluster
- group of patient data or cues that point to existence of health problem
- nursing dx should be derived from clusters of significant data rather than from a single cue.
Dx: Standards
- be familiar w other standards used in data analysis
- i.e. BP, norm values for pt’s age, race, illness category
- pts own normal range is important standard.
Types of Dx
- Actual: prob current for pt.
- Risk: pt has no ss but is likely to develop
- Possible: added data needed to determine if problem exists or can rule out
- Wellness: desire for increased wellness
- Syndrome: represent situation of event.
Components of Nursing Dx statement
- Nursing Dx
- Etiology
- Defining characteristics
(Nursing Dx) related to (Etiology) as evidenced by (defining characteristics)
Nursing Dx
- Nanda-I approved
- identified by its definition, defining characteristics and risk factors
- Categorizes patient problem from clustered assessment data or cues
Etiology
- factors that cause the health problem
- connected to nursing dx w term “related to”
- nursing care directed toward etiology may alleviate the patient problem
Defining Characteristics
- supports identified health problem or nursing dx.
- Linked to etiology with term “as evidenced by”
Revising Nursing Dx
modified as new or additional assessment data becomes available or patient condition changes.
