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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"
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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~
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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
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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
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Nursing Process
The purpose of Assessment
To collect data, is can be about client background, health status capability, ability to manage own health care.
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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.
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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.
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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.
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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
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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)
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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
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The Nursing Process
Ideally the outcomes should...
- 1)promote wellness
- 2)prevent illness and disease
- 3)restore health
- 4)facilitate coping
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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
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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.
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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**
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The Nurse Process
List the characteristics of the Nurse Process.
- 1)Systematic
- 2)Dynamic
- 3)Interpersonal
- 4)outcome/goal oriented
- 5)universally used
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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.
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The Nurse Process
Primary VS. Secondary
- Primary- Interview(nursing history), Physical examination
- Secondary- Family, other health care providers, medical records health care literature
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