A systematic problem solving approach toward giving individualized nursing care.
6 components of the nursing process:
1. assessment
2. diagnosis
3. outcome identification
4. planning
5.implementation
6.evaluation
What is a primary source of data?
The patient
What are secondary sources of data?
Family members, significant others, other health professionals, health records, etc.
Define Assessment:
A systematic collection of subjective and objective data with a goal of making a clinical nursing judgement about an individual,family, or community.
Define Diagnosis:
Clinical act of identifying problems. Analyze assessment data and derive meaning from it.
Define Outcome Identification:
Formulating measurable, realistic, patient focused goals. Integral part of nursing process.
Define Planning Phase:
Involves preparing a plan of care which directs the activities of the nursing staff in the provision of patient care.
What is a plan of care?
A written summary of the care the patient is to receive. (JCAHO requires a written plan of care for every patient.)
After gathering data, the nurse performs an analysis of the information and derives meaning from the analysis. What phase of the nursing process is being used?
Diagnosis
What activity should a nurse do during the outcome identification phase of the nursing process?
Which of these is a feature of the decision-making process?
B) Priorities change to meet emergency needs.
What is a characteristic feature of the nursing process?
It is a framework for providing care.
According to the Systems Theory, input is the information that enters a system. What step in the nursing process corresponds to input?
Assessment-data collected through observation, interview, and physical exam.
What activity should a nurse perform to ensure accuracy in the selection of a correct diagnosis?
Perform cue clustering
What skills are used during the implementation phase?
Technical skills
A nurse is assigned to a semi-concious patient. How should the nurse gather assessment data?
A) Perform physical assessment
Define Implementation Phase:
Action phase of nursing process. Initiation of plan of care, evaluation of response to plan and recording nursing actions and patient responses.
Define Evaluation Phase:
Rating, grading, and judging success or failure of care plan. Evaluation in ongoing and continuous and is performed throughout all phases of nursing process.
