1 Flashcards
- Is a systematic, rational method of planning, and providing quality and individualized nursing care.
- Series of phases describing the practice of nursing
- GOSH approach for efficient and effective provision of nursing care.
Goal oriented
Organized
Systematic
Humanistic care
The Nursing Process
- Cyclic and dynamic
- Client centered
- Universally applicable
- Focus on problem solving
- Interpersonal collaborative
- Used to critical thinking
Characteristic of nursing process
- Goal oriented
- Organized
- Systematic
- Humanistic
- Efficient and effective nursing care
According to Udan
5 steps of the Nursing Process
- Assessment
- Diagnosis
- Planning
- Intervention
- Evaluation
- Collection, organization, validation and documentation of data. The most important step.
- Begins during the first meeting of the nurse and the client
- Continuous process carried out during all phases of the nursing process. Identifies the patient’s strengths and limitations.
Assessment
4 sections of Assessment
- History of present health concern
- Past health history
- Family history
- Lifestyle and health practice
Steps of assessment
- Collection of data
- Organizing data
- Validation of data
- Documentation of data
Sources of data
o Primary
o Secondary
- Data elicited and verified by the client
- Client, Client record, Other healthcare professionals
- Client interview
- Interview and therapeutic communication skills
examples:
- “I can’t breathe” , “I have a stomach pain”, “I can’t sleep”
SUBJECTIVE
Types of data
SUBJECTIVE
OBJECTIVE
- Data directly/indirectly observed through measurement
- Observation and physical assessment findings of the health professionals
- Documentation of the assessment made in the client record
- Observation made by the family or significant others
- Observation and physical examination
examples:
- Heart rate of 110bpm
- UTZ reveals the client is pregnant for 18weeks
- X-ray film reveals PTB
OBJECTIVE
- A statement or conclusion regarding the nature of phenomena
- Analyzing subjective and objective data to make
a professional judgement - Provides basis for the selection of nursing
intervention
Diagnosis
about individuals, family, or
community responses to actual and potential
health problems and life process.
- Clinical judgement
Types of Nursing Diagnosis
Wellness Diagnosis
Actual Diagnosis
Risk Diagnosis
Possible Diagnosis
Syndrome Diagnosis
Describes human response to level of wellness in an individual, family, or community that have a readiness for enhancement
Wellness Diagnosis
Problem is present (+) signs and symptoms
Actual Diagnosis
Problem does not exist, but the present of risk factors indicate a problem is likely to develop unless nurses intervene
Risk Diagnosis
Health problem is incomplete or
unclear
Possible Diagnosis
Associated with a cluster of other diagnosis
Syndrome Diagnosis
words that have been added to NANDA labels to
give additional meaning
o Deficient
o Impaired
o Decreased
o Ineffective
o Compromised
Qualifiers
- Deliberative, systematic phase of nursing process that involves decision making and problem
solving - Involves setting goals and outcomes
- Individualized plan of care for patient once diagnosis have been prioritized.
Planning
Planning should be:
Specific
Measurable
Attainable
Realistic
Time-bound
- Also called “Intervention”
- Putting the nursing care plan into action
- Purpose: to carry out planned nursing interventions to help the client attain goals and achieve optimal health.
- Any treatment based on clinical judgement and knowledge that a nurse performs to enhance patience outcomes.
- The “doing” phase
Implementation
Actions that require an order from a health care provider
Dependent
