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Stack #66233

Fundamentals-Nursing Process

Nursing process systematic, rational method of nursing care
descision making process identify purpose, set criteria, weigh criteria, seek alternatives, examine alternatives, project, implement, evaluate
Assessing collect, organize, validate,document data
Diagnosing analyze data, identify risks & strengths, formulate diagnostic statements
Planning Prioritize,formulate goals and outcomes,select interventions, write orders
Implementing reassess,implement interventions,delegate,document
Evaluating compare data to outcomes, draw conclusions, modify care plan
subjective data symptoms only the pt. can verify
objective data signs detectable to observer
directive interview highly structured, elicits specific info
nondirective interview rapport building interview
cephalocaudal approach head to toe approach
Maslow's Theory heirarchy of needs
validation double checking data to confirm accuracy
cues what pt. says or nurse sees
inferences nurses interpretation
diagnosis statement regarding the nature of problem
risk factors diagnosis indicates a problem that could develop
wellness diagnosis readiness for enhancement of wellness
possible diagnosis evidence is incomplete
syndrome diagnosis associated with a cluster of other diagnoses
diagnostic 3 part statement PES
Problem statement of clients response
Etiology factors contributing to probable cause of response
Signs and Symptoms defining characteristics manifested by pt.
nursing intervention any treatment based on clinical judgment that a nurse performs
formal care plan written or computerized guide
informal care plan strategy that exists in the nurses mind
standardized care plan formal plan for all individuals with same etiology
individualized care plan tailored for specific pt.
Nursing Care Classification (NOC) standardized nursing language
indicator concrete observable state of behavior