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10 Cards in this Set
- Front
- Back
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Assessment |
Data collection: Primary data (patient interview) Secondary data Subjective data (symptoms/health history) Objective data (signs, physical exams, lab results, diagnostic test results) |
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Evaluation |
Care plan evaluation (Patient goal/outcome attainment?)
Continue? Revise/adapt? Discontinue? |
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Implementation |
Interventions (Independent, dependent, collaborative care, direct, indirect)
Documentation (NIC) Care plans (clinical pathways, protocols, standing orders) |
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NANDA-I |
a professional nursing organization that provides standardized language to identify patient problems and plan customized care |
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Nursing Diagnosis |
Identifies an actual or potential problem or response to a problem |
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Nursing Process |
systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care to aptients |
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Outcome Identification |
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Planning |
Prioritize nursing diagnoses personalize care plans - short term -long term Outcome Identification (NOC) |
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Diagnosis |
Types: - Actual - Risk - Health Promotion |
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Cyclic nature of the nursing process |
It is crucial that the professional nurse continuously reassess the patient, revise the care plan as needed, and evaluate whether the patient's goals are being met |
