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T1-Nursing Process
Outline Lecture Notes - FI
| Question | Answer |
|---|---|
| Name the 5 components of the Nursing Process | Assessment, Nursing Diagnosis, Planning, Implementation, Evaluation |
| Describe the Assessment component of the Nursing Process | Collecting & organizing info about the client's health status. Establish baseline of info by gathering info. |
| What are the types of Data Collection | Subjective (Symptoms) and Objective (signs) |
| What consists of Objective data? | The signs observed or measurement taken during assessment |
| What consists of Subjective data? | The symptoms or perceptions that the pt tells you about |
| What are the types of Sources of Data? | Primary (Direct) or Secondary (Indirect) |
| Explain primary source of data | Information received directly from the pt |
| Explain secondary source of data | Information received from others, lab data, records, reports |
| Describe the Nursing Diagnosis component of the Nursing Process | Statement describing the pt's response to a situation resulting in actual or high risk health probs that RN can ID or treat |
| What does the diagnostic process consist of? | Consists of decision-making steps that one uses to develop a diagnostic statement. Consists of Cluster data, validating findings c diagnostic cat., & choose diagnostic cat. that best fits data |
| Define cluster data | Analyzing collected data from assessment |
| What are the types of nursing diagnoses | Actual & High Risk (Potential) |
| Describe the Actual type of Nursing Diagnoses | 1) Prob (Diagnostic Category) related to "R/T". 2) Etiology/cause (Contrib or Risk Factors) as manifested by "AMB". 3) Signs/Symp (Defining Charact.): expressions, observations, & behaviors of pt |
| Describe the High Risk (Potential) type of Nursing Diagnoses | 1) Prob (Diagnostic Category) related to "R/T". 2) Etiology/cause (Contrib or Risk Factors) the validation for this nursing Diagnosis is the presence of risk factors, No S/S |
| Describe the Planning component of the Nursing Process | Set priorities, goals are determined, expected outcomes are developed, & NCP is formulated. |
| During Planning, explain how to prioritize nusing diagnoses | High priority: Urgent and immediate Intermediate priority: Not life threatening Low Priority: Not directly R/T specific illness or prognosis |
| During Planning, explain how to set goals with outcome criteria | Purpose: Provide direction for 1) Planning nursing actions @ eliminate/relieve prob or to correct the etiology of the prob & 2) evaluating the effectiveness of nursing actions, Client centered (directed from pt), Include goal statements, Types of goals |
| Explain the different types of goals that should be set in the Planning component of the Nursing Process | 1) Short term: goals achieved in short period of time. 2) Long term: goals achieved over longer time frame. 3) Design ursing interventions (actions). 4) Types of Care Plans |
| Describe the Implementation component of the Nursing Process | Involves actually carrying out of the plan of care |
| Describe the Evaluation component of the Nursing Process | Determines to what extent goals have been met and how effective interventions were. Ea goal & intervention should be evaluated specifically |
Created by:
mcwilliams05
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