Question | Answer |
Steps of nursing process | 1. Assessment 2. Nursing diagnosis 3. Planning 4. Implementation 5. Evaluation |
Define nursing process | a systematic, rational method of planning and providing nursing care. |
Nursing process | Orderly, logical approach to providing nursing care and ensuring that patient needs are met. |
Assessment | collect, organize, validate and document patient data |
Diagnosing | Analyze and synthesize data |
Planning | Determine how to prevent, reduce, and resolve client problems |
IMPLEMENTING | Perform planned nursing interventions, reassessment of the patient and documentation |
EVALUATION | Measure the degree to which goals have been achieved |
4 types of assessments | 1. Initial
2. Problem-focused
3. Emergency
4. Time-lapsed reassessment |
Collecting Data | Gathering information about client’s health status
Where? - physical assessment - Primary Health care providers history and physical - Results of labs and diagnostics - Healthcare teams documentation |
Organizing Data | Writing data into an organized format |
Validating Data | Verifying that data is complete and accurate |
Documenting Data | Recording data in a factual manner |
Nursing health history | Biographic data
Chief complaint or reason for visit
History of present illness
Past history
Family history of illness
Lifestyle
Social Data
Psychological Data
Patterns of Health Care |
Subjective data | Symptoms
Described, verified by the person affected
Includes: sensations, feelings, values, beliefs, attitudes and perceptions |
Objective data | Signs
Can be observed, measured, & tested
Obtained by Observation or physical examination |
Sources of data | Client
Support People
Client Records
Health Care Professionals
Literature |
Data collecting methods | Observing
Interviewing
Examining |