Unit 1 Flashcards
Rn Role Assessment
complete and analyze a comprehensive assessment of the patient within the physiological, psychological, social, cultural, and spiritual realms.
Rn role Dx
fully analyze assessment cues into identifying criteria and formulate individualized nursing dx
rn role outcome ID/planning
prioritize nursing dx and interventions to be carried out by the health care team
rn role Implementation
direct & carry out nursing interventions, participate in the implementation of collab interventions and follow up
rn role evaluation
evaluate progress adjust POC accordingly
Lydia Hall
1955
Ida Jean Orlando
1958 created a process model for nurses to use to plan the care of (referred to as nursing process by 1961) 3 step process - assessment, planning, evaluation
Yura and Walsh
1967 developed a four step assessment, planning, implementation, and evaluation
ANA 1973
added fifth step - diagnosis
mission of NANDA-I
to facilitate the development, refinement, dissemination, and use of standardized nursing diagnostic terminology
1991 ANA added
outcome identification added
ADPIE
assessment, diagnosis, outcome identification/planning, implementation, evaluation
complex, purposeful, and disciplined process driven by needs of pt and family
critical thinking
objective data
facts that can be measured and verified (VS, size of wound…)
subjective data
experienced only by pt (pain, nausea, uneasiness, fear)
interview
dialogue session c the pt or people c the pt
observation
collection of data through senses (seeing, listening, smelling, touching) includes environment
physical assessment
collection of objective data (inspection, auscultation, palpation, and percussion) focuses on functional ability to focus the POC
PES
problem, related to (etiology), s/sx (AEB)
