Intro to nurse process

  1. Intro to Nurse Process
    Florence Nightingale definition of nursing in 1860
    "the act of utilizing the environment of the client to assist him in his recovery"
  2. Intro to Nurse Process
    In 1980 the American Nurses Association (ANA) published this definition of nursing 1980:
    • "Nursing is the diagnosis and treatment of human responses to actual and potential health problems"
    • ~which is also from the NY state class practice act~
  3. Intro to Nurse Process
    The steps in the in Nursing process. "AD PIE"
    1) Assessment 2)Nursing Diagnosis 3)Outcome identification and planning 4)Implementation 5)Evaluation
  4. Nursing Process
    What activities goes in to the Assessment Stage?
    • 1)Collection of data
    • ~vital signs ~observing appearance
    • ~asking question ~family ~physical assessment
    • ~consult w/ other health care professionals
    • 2)Validation
    • ~restating communication ~family ~physical assessments ~health care providers
    • 3)Communication of data
    • ~verbal reports ~documentation ~depending on hospitals
  5. Nursing Process
    The purpose of Assessment
    To collect data, is can be about client background, health status capability, ability to manage own health care.
  6. The Nursing Process
    What is and the purpose of a Nurse diagnosis?
    • ~Analysis of data regarding the client to identify strengths and unmet needs problems (actual and potential).~
    • Purpose= Develop appropriate list of nursing diagnosis and prioritize them.

  7. The Nurse Process
    The activities that go into nurse diagnosis
    • ~Organize and analyze data. Helps with defining what the persons strengths are and what actual or potential problems there are.
    • ~then formulate the nursing diagnosis and validate it by the defining characteristics
    • ~Finally, prioritize the diagnosis using background you already have.
  8. The Nursing Process
    Describe what is and the purpose of Out come identification and planning?
    • ~Establishing 1)client's outcomes (goals) to prevent, reduce, or resolve problems identified in the nursing diagnosis. 2) interventions to achieve the outcomes.(goals)
    • Purpose= develop and individualize plan of care based on data (from Step1) and analysis (from step2) Develop individualize plan of care. 
  9. The Nursing Process
    What is important to think about when considering a care plan.
    • ~ Consulting with patient
    • ~make sure the both you have the same goal
    • ~make sure they agree with your care plan
    • ~involve them  
  10. The Nursing Process
    The outcome identification and planning activities
    • 1)Write goals that are measurable (outcome identification)
    • 2)Define nursing intervention that help to achieve that goal.
    • 3)Once goal is present communicate with other health care providers. (partnership care)
  11. The Nursing Process
    What is and the purpose of Implementation (the doing step)
    • ~Carrying out plan of care
    • Purpose=Assist client to achieve desired out comes     
  12. The Nursing Process
    Ideally the outcomes should...
    • 1)promote wellness
    • 2)prevent illness and disease
    • 3)restore health
    • 4)facilitate coping  
  13. The Nursing Process
    What activities goes with the Implementation stage.
    • ~Carry out plan of care
    • ~still assessing (see how they are responding)
    • ~Documenting
    • ~still communicating
    • ~looking over care plan for gaps
  14. The Nurse Process
    What is and the purpose of the Evaluation stage?
    • ~Measuring the extent to which the client has achieved the outcomes, identifying factors that positively or negatively outcomes achievement, and revising the plan of care if necessary.~
    • Purpose= to continue care if plan is working or stop if isn't or if the patient is well.
  15. The Nurse Process
    What activities comes with the evaluation stage?
    • ~Measuring how well the patient has achieved desired outcomes.
    • ~Identify things that seem to be contributing to success, or things that are barriers maybe.
    • **Evaluating is really assessing again & comparing to the outcome that we hoped to achieve**
  16. The Nurse Process
    List the characteristics of the Nurse Process.
    • 1)Systematic
    • 2)Dynamic
    • 3)Interpersonal
    • 4)outcome/goal oriented
    • 5)universally used  
  17. The Nurse Process
    Subjective VS. Objective
    • Subjective~ From the patient, typically a symptom. Best indicated by a quote.
    • Objective~ Any thing that can be seen felt heard by the nurse. Can be observed by more then one person. 
  18. The Nurse Process
    Primary VS. Secondary
    • Primary- Interview(nursing history), Physical examination
    • Secondary- Family, other health care providers, medical records health care literature
Card Set
Intro to nurse process