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Nur 221 Nur. Process

Nursing Process

A systematic problem solving framework that guides nursing actions The nursing process
What are the 5 steps of the nursing process? Assessment- Nursing Diagnosis- Planning- Implementation- Evaluation
According to the the ANA what is the Nursing process? Professional nurse’s approach to identify, diagnose, and treat human responses to health and illness
What is the purpose of the Nursing process? Identify patients needs Determine the clients Priorities Establish goal and expected outcomes of care
What are other purposes of the Nursing process? Communicate patient plan of care Provide Nursing interventions to meet clients needs Evaluate the effectiveness of the outcomes and goals of overall care.
Define assessment Systematic collection of data to determine the clients past and present health status, their functional status and determines the past and present coping patterns.
What is the process of Assessment? Data collection interpretation and validation of data clustering data to form data base.
What is the primary source of data? Client
What are other sources of assessment data? Family members, health professionals, medical record.
What is the definition of a nursing diagnosis? A Nursing Diagnosis is a statement that describes the clients actual and potential response to a health problem that a nurse is licensed and competent to treat.
What are the types of nursing diagnosis? Actual and Risk
What does Planning include? Determining client centered goals and outcomes Selecting nursing interventions Writing scientific rationales
What is Implementation? Giving interventions
What is evaluation? Evaluating your goals for your client and if they met expected outcomes
What is the product of Planning? Nursing Care Plans
Date given by the patient or patient family. Symptoms of "how they feel" Subjective data
observation and measurable data. Able to be compared to an accepted standard or value Objective data
What is Nanda? North American Nursing Diagnosis Association
A problem that currently exist with data to support the diagnosis Actual Diasnosis
At risk for a problem that may develop. No signs or symptoms at present Rick Dianosis
1 Identify & start with label (NANDA)2 Etiology (may have secondary statement; medical diagnosis)3 AEB - Defining characteristics (signs/symptoms)4 Avoid judgement statements5 Avoid suggesting that a team member is not doing his/her job Rules to remember when writing a Nursing Diagnostic Statemen
Establish priorities based on Maslow's Hierarchy-Develop goals with measurable outcomes-Design nursing interventions Notes to remember for the planning phase of the nursing process
patient centered (the patient will...)-singular, one goal per statement-realistic for patient-measurable/observable-time limited-mutual-long or short term-Who, what behavior, how measured, when Guidelines for Formulating/Writing Goals
Nursing centered (the nurse will...)-Independent, Dependent, Collaborative-based on related factors-Focus activities to promote, maintain, or restore health-Theoretical base/rationale (evidence based)-May be diagnostic, therapeutic, educational Planning phase for Nursing Actions/Interventions
step in the nursing process where nurses provide direct and indirect nursing care interventions to patients-requires the nurse to use appropriate cognitive, interpersonal, and psychomotor skills Implementation
-patient centered/patient goal acheivement-ongoing process that enables the nurse to determine progress the patient has made in meeting the goals for care Evaluation
Scientific reasoning for selecting a specific nursing action. Rationale
Subject (nurse, but do not write, "The nurse will", this is understood). Action verb - what the nurse will do. Descriptive qualifiers - how or what and where to perform action. 4. Specific times - when, how often, how long, specific dates and times. Components of a nursing order.
The nursing process is not linear, infact it is dynamic and contiunous
Created by: dgreen158