Nursing process Flashcards
(50 cards)
Assessment
Collection, verification, and analysis of data
Activities of daily living (ADL’s)
Activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, and grooming)
Patient centered goal
Reflects a patients highest possible level of wellness and independence in function
Counseling
Direct care method that helps a patient in the problem-solving process to recognize and manage stress and facilitate interpersonal relationships
Data base
The patients perceived needs, health problems, and responses
Data clustering
Set of signs and symptoms gathered during the assessment that you grouped together in a logical way
Data collection
information comes from: the patient through interview, observations and physical examination. Family members or significant others’ reports and responses to interviews. Other members of the healthcare team. Medical record information. Scientific literature.
Defining characteristics
Clinical criteria that are observable and verifiable
Delegation
Non invasive tasks (ADL’s and vitals). Nurses who assigns the tasks are responsible for ensuring that each task is appropriately assigned and completed according to standards of care. The person that was given the task must be competent.
Dependent interventions
Actions that require an order from the physician or another healthcare provider
Etiology
The cause of the nursing diagnosis within the domain of nursing practice
Expected outcomes
A measurable criterion to evaluate goal achievement
Implementation
Begins after the nurse develops a nursing plan, based on clear and relevant nursing diagnoses; designed to achieve the goals and expected outcomes, needed to support or improve the patients health status.
Independent interventions
Actions that a nurse initiates, does not require an order from another healthcare professional
Interdependent interventions
Therapies that require the combined knowledge, skill, and expertise of multiple care professionals
Health Interview
Characteristics: organized convo. Confidential, and focused and systematic.
Medical record
Use of current and past medical records to retrieve info that might be helpful
Medical diagnosis
Illness that reflect alteration of the structure or function of organs or systems
Nursing diagnosis
Addresses human responses to actual or potential problems or processes
Nursing process
A systematic process;The process of problem-solving method of planning and providing individualized care for patients and clients.. Ongoing and something that is done continuously
Standing order
Preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific patients is identified clinical problems
Benefits of nursing process
Unifying concept; provides a framework Communication (in a common language) Individual focus Patient is an active participant Cost effective
Steps of the nursing process
Assessment problem identification (nursing diagnosis) planning implementation evaluation
Sources of data
Primary and secondary
