Nursing Process Flashcards
Nursing Diagnosis (compared to medical Dx)
Statement of pt health status that nurses can identify, prevent, or treat independently/ in collaboration w other health providers
Ex. Pain r/t decreased circulation to feet m/b verbalization of 8/10 on pain scale
Medical Dx
Specific disease process using medical terminology
Focuses on disease & pathology
Diabetes mellitus, hypertension, etc
Types of nursing Dx
- actual problem
- possible problem/suspected problem
- syndrome- several related problems are present (DM)
- wellness- no problem present, focus on prevention
Nursing process: Planning
-planning outcomes/goals
Pt oriented, realistic, r/t nursing Dx, have time frame
-planning interventions
Used to meet pt goals, resolve pt problem, r/t plan of care & nursing Dx & medical plan
Nursing process: assessment
Collect data
- interview (pt, family, friends)
- physical assessment
- Dx tests
ANA standards for clinical practice (main points)
- define activities specific + unique to nursing
- apply to all nurses
- protect nurse, pt, healthcare institution
Objective data
Gathered through physical assessment, measurable
Subjective data
Info supplied by pt that cannot be perceived by another person
(Nauseous, pain, tingling)
Types of assessments
Initial
Ongoing
Comprehensive
Focused
Nursing Process: Dx
Analyze data identify patterns Cluster data, draw conclusions Identify relevant/ irrelevant data Identify problems
Use Maslow to identify threats and prioritize to determine nursing Dx
Types of nursing interventions
-independent
Nursing orders
-dependent
Nursing actions, carrying out physician orders
-interdependent
joint intervention by RN and others in care team
Nursing Process: Implementation
- doing, delegating, documenting
- promote pt participation and adherence to care plan
- collaborate and coordinate care
Nursing Process 5 steps
A-assessment D-Dx P- planning goals/ outcomes, interventions I- implementation E-evaluation
How to formulate nursing Dx
- pt problem
- nursing Dx- pick from list
- r/t etiology/ cause of problem
- m/b signs and symptoms- assessment data
5 Rights of delegation
Right task- can I delegate this?
Right circumstance- is client stable?
Right person- can delegate do this competently?
Right communication- clear & specific about each task
Right supervision- monitor delegate’s work, intervene if necessary, get/provide feedback, evaluate pt outcomes, ensure proper documentation
