9 nursing process

  1. what are the nursing process steps
    • assessment
    • diagnosis
    • planning/outcome and identification
    • implementation
    • evaluation
  2. a series of steps or acts that lead to accomplishing some goal or purpose
  3. 3 characteristics of processes
    • purpose
    • internal organization
    • infinite creativity
  4. a systemic method for providing care to clients
    nursing process
  5. this purpose is to provide individualized holistic effective cliect care efficiently
    the nursing process
  6. used with all clients in any care setting
    nursing process
  7. first step in the nursing process that includes systematic collection, verification, organization, interpretation and documentation of data
  8. purpose of assessment is to
    identify clients strength and give nurses information about the abilities, behaviors, and skills the client can use during treatment and recovery
  9. types of assessments
    • comprehensive
    • focused
    • ongoing
  10. provides baseline client data including a complete health history and current needs assessment. usually completed upon admission
    comprehensive assessment
  11. limited to potential health care risks, particular needs, or health care concerns. not as detailed and often used in short stays
    focused assessment
  12. includes systematic monitoring of specific problemsand is used when follow up is required
    ongoing assessment
  13. client is considered the _____ source of data. the major provider of information about a client
  14. source of data that is gathered by family members, other health care providers and medical records
    secondary source
  15. data from the cleints point of view that includes perception, feelings, adn concerns. primary way of collecting data
    subjective data
  16. review of the clients functional heatlth pattern prior to the current contact with the health agency, provides much of the subjective data
    health history
  17. observaable and measurable data that are obtained through both standard assessment techniqes and results of labs and diagnostic testing and physical exams
    objective data
  18. process of putting data together in order to identify areas of the clients problem and strength
    data clustering
  19. a framework providing a systematic way to organize data
    assessment model
  20. initial assessment of all physiological needs followed by assessmnet of higher level needs thorugh this model
    maslows hierarchy of needs
  21. model that organizes data collection according to issue and organ function in various body systems
    body system model
  22. data collected through 11 functional health patterns
    11 functional health patterns
  23. developed on clients ability to perform self care activities
    theory of self care
  24. when data is placed in clusters the must be able to
    disinguish between relevent and irrelevent data, identify cause and effect
  25. second step in nursing process that involves further analysis and synthesis of collected data
  26. breaking down of the whole into parts that can be examined
  27. putting data together in a new way
  28. clinical judgement by the physician that identifies or determines a specific disease, condition, or pathological state
    medical diagnosis
  29. related cause or contributor to the problem
  30. 3 components of nursing diagnosis
    • 1. actual nanda diagnosis
    • 2. related to
    • 3. and AEB
  31. nursing diagnosis that idicates that a problem exists and is composed of diagnostic labels and s/s
    actual nursing diagnosis
  32. nursing diagnosis with a potential problem. problems that does not yet exist but risk is present
    risk nursing diagnosis
  33. denotes a clients statement of a desire to attain a higher level of wellness in some area of function
    wellness nursing diagnosis
  34. certain physiologic complications that nurses monitor to detect onset or changes in states. always begins with PC - potential complication
    collaborative problems
  35. 3rd step in the nursing process that includes both establishing guidelines for the proposed course of nursing action to resolve the nursing diagnosis and developing the clients plan of care
  36. involves development of a peliminary plan of care by the nurse who perfomrs th aadmission assessment and gathers the comprehenssive admission data
    initial planning
  37. updates the clients plan of care
    ongoing planning
  38. involves anticipation of and planning for the clients needs after discharge
    discharge planning
  39. 3 level pproach to prioritizing clienst problems
    • first level priority problem
    • Airway
    • Breathing
    • Signs (vital sign problems)

    • second level priority
    • Mental status change
    • Acute pain
    • Acute urinary elimination problems
    • Untreated medical problems
    • Abnormal lab values
    • Risk of infection

    • Third level priority
    • Other health problems
  40. an aim, intent, or end
  41. statement that profiles the desired resolution of the nursing diagnosis over a short period of time
    short term goal
  42. profiles desired resolution over a long period of time
    long term goal
  43. specific statemtn describing the methods to be used to acheive the goal
    expected outcome
  44. an action perfomed by th enurse that helps th eclient achieve the results specified by th egoals and expected outcomes
    nursing intervention
  45. 3 categories of nursing intervention
    • independent
    • interdependent
    • dependent
  46. initiated by the nurse and do not require direction or an order from another healh care professional
    independent nursing intervention
  47. implemented collaboratively by th enurse in conjunction with other health care professionals
    interdependent intervention
  48. require an order from a physician or other healthcare professional
    dependent nursing intervention
  49. written guid eor strategies to implement to help the client acheive optimal health
    nursing care plan
  50. is individualized, standardized and begun on the day of admission and continually updated until discharge.
    care plan
  51. 4th step in nursing process. performance of the nursing intervention identified during the planning phase
  52. an order written in a clients medical record by a physician or nursing care plan by th enurse especially for that individual client . not used for any other client
    specific order
  53. series of standing orders or procedures that should be followed under certain specific conditions
  54. 5th step in nursing process . determines weather client goals have been met, partially met, or not met.
  55. what should a nurse do if a goal is partially met or ot met
    reassess the situation
  56. what should a nurse do if the goal is met
    decide to stop or continuefor the status to be maintained
  57. avoid making decisions based on wat type of information
    outdated, inaccurate, or incomplete information
  58. primary reasons for documentation
    responsibility and accountability
  59. establish guidelines to ensure safe practice and to demonstrate accountabilityto society
    state nursing practice acts
  60. how can informed consent be given
    orally or in writing
  61. a competent client ability to make health care decisions based on full disclosure of benefits, risks, and potential consequences of a recommended treatment plan
    informed consent
  62. who is responsible for obtaining the clients informed consent
  63. who often has the client sign the informed consent
  64. written instruction about an individuals health care regarding life sustaining measures
    advance directive
  65. elements of effective documentation
    document accuratly, completly, objectively

    note date and time

    use standard abbreviations

    write in ink and use appropriate forms

    spell correctly

    write legibly

    sign each entry

    chart on every line
  66. when should medications be charted
    immediatly after administration
  67. a brief worksheet that is traditionally not apart of client medical record. has basic cleint care info
  68. kardex info contains
    • name
    • age
    • marital status
    • religion
    • medical dx
    • nursing dx
    • allergies
    • medical orders
    • activities permitted
  69. occurance report or variance report documents any ususual occurance or accident in the facility
    incident report
Card Set
9 nursing process