| 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 |
