Lecture 2: The Nursing Process Flashcards
marian’s motto
all good nursing care begins with: a good assessment
What is the nursing process
- assessment: collect organize data
- diagnosis: identify present health status
- planning: choose nursing interventions
- implementation: carry out plan
- evaluation: determine if plan was effective
nursing theories define or describe nursing as
- art and science with its own evolving scientific body of knowledge
- holistic
- involves caring
- occurs in a variety of settings
- concerned with health promotion, disease prevention, and care during illness
types of problems you can have
- biological
- psychological
- social
- spiritual
whats classified in assessment
- collect data
- validate conflicting data
- organize and record data
what’s classified in diagnosis
- sort, cluster and analyze data to identify the pt’s present health status
- write a precise statement describing the pt’s present status and contributing factors
- prioritize the diagnosis
- decide proper respond to nursing care
format for writing diagnositc statements
Problem ->
related to/caused by
Etiology ->
as evidenced by/resulting in
Signs and Symptoms
what are SMART goals
specific
measurable
achievable
realistic
timely
whats classified as planning
- planned outcomes are the desired pt outcomes
- goals should be pt-centered and mutally set if feasible
- set both short and long term goals
- outcomes are the result of care
what’s classified in planning interventions
- how can you help achieve the outcome
identify dependent and independent nursing interventions - the who/what/when/how
what is evalution
- what were the outcomes
- short/long term goals
- did the interventions work
- does the plan of care need to be continued, discontinued, or revised
- evaluation data becomes new assessment data
2 types of documentation
- charting by inclusion (narrative) - in chronological order
- charting by exception (focused) - completed when vary from established norms or standards of care
DARP charting
Data
Analysis and action
Response
Plan
Focuses on:
- Pt concern or behaviour
- a change in pt/client condition
- significant treatment event
SOAP charting/SOAPIER
Subjective
Objective
Assessment
Plan
Implementation
Evaluation
Revision
whats a cue
physiologic or psychosocial changes
