3802 Nursing Process Exam 1
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| -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)
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| Forms the foundation for decision-making and encompasses all significant actions taken by nurses | Nursing Process as defined by the ANA Practice Standard
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| 1. Assessment2. Diagnosis3. Planning4. Implementation5. Evaluation | 5 Steps of the Nursing Process
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| gathering/collecting patient information | Assessment
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| identifying the patient's problem(s) | Diagnosis
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| setting goals and identifying appropriate nursing actions | Planning
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| performing nursing actions identified in planning | Implementation/Intervention
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| determining if goals are acheived | Evaluation
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| active, organized, cognitive process used to carefully examine one's thinkingexploring underlying thoughts & processes of decisions | critcal thinking
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| Interpretation, Analysis, Evaluation, Inference, Explanation, Self-regulation | Critical Thinking Skills
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| Confidence, Thinking independently, Fairness, Responsibility & Authority, Risk taking, Discipline, Perseverance, Creativity, Curiousity, Integrity, Humility | Critical Thinking Attitudes
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| data reported by the patient in their own words | Subjective Data
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| observed or measured data collected about the patient | Objective Data
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| -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
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| -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
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| -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
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| 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
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| -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
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| -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
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| -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
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| 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
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| -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
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| 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
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| -Nursing Process criteria-List of approved Labels-Patient's data-Patience, learn to think like a nurse | Care plan tools
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