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3802 Nursing Process

3802 Nursing Process Exam 1

-A problem solving approach to provide care in an organized, scientific manner-Consists of 5 interrelated steps-Dynamic & continuous process-Promotes individualized nursing care-Requires critical thinking Nursing Process (generally)
Forms the foundation for decision-making and encompasses all significant actions taken by nurses Nursing Process as defined by the ANA Practice Standard
1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation 5 Steps of the Nursing Process
gathering/collecting patient information Assessment
identifying the patient's problem(s) Diagnosis
setting goals and identifying appropriate nursing actions Planning
performing nursing actions identified in planning Implementation/Intervention
determining if goals are acheived Evaluation
active, organized, cognitive process used to carefully examine one's thinkingexploring underlying thoughts & processes of decisions critcal thinking
Interpretation, Analysis, Evaluation, Inference, Explanation, Self-regulation Critical Thinking Skills
Confidence, Thinking independently, Fairness, Responsibility & Authority, Risk taking, Discipline, Perseverance, Creativity, Curiousity, Integrity, Humility Critical Thinking Attitudes
data reported by the patient in their own words Subjective Data
observed or measured data collected about the patient Objective Data
-pivotal point in nursing process-clinical judgement about human response to actual & potential health problems-basis for selection of nursing actions/interventions-specific nursing care statement Nursing Diagnosis
-Describes a clinical judgement that the nurse has validated because of the presence of defining characteristics-Label + Etilogy/contributing factors + Signs & symptoms patient is manifesting Actual Nursing Diagnosis
-Describes a clinical judgement that an individual/group is more vulnerable to develop the problem than others in the same or similar situation because of risk factors, aimed at prevention-Label + Etiology/Factors that cause/contribute to the problem Risk Nursing Diagnosis
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 Statement
-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
1 Critical thinking2 Experiential & Theoretical Knowledge3 Interpersonal Communication Skills4 Technical Skills5 Willingness & Ability to care What it takes to be competent when using the nursing process
-Nursing Process criteria-List of approved Labels-Patient's data-Patience, learn to think like a nurse Care plan tools
Created by: garzakd