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9 Cards in this Set
- Front
- Back
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What are the steps of the Nursing Process? |
Assessment Diagnosis Outcome Identification Planning Implementation Evaluation |
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Define: Assessment |
Collection of data from multiple sources |
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Examples of assessment |
review of clinical record, interview, health history,physical examination, functional assessment, cultural and spiritual assessment, consultation, review of literature
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Database is formed from what? |
Subjective and Objective data plus patient’srecord and laboratory studies
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Diagnosis |
-Interpretation of data by identifying clusters of cues so as to make inferences
-Compare clusters of cues with definitions and defining characteristics -Validation of inferences based on findingsIdentify related factors -Document the diagnosis |
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Outcome Identification |
-Identify expected outcomes related to patient individualization
-Ensure outcomes have the SMART components -Specify short-term and long-term goal measurement criteria |
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Planning |
-Establish priorities based on meeting identified patient care goals
-Develop outcomes and set time frames for meeting proposed outcomes -Identify relevant interventions and utilize interdisciplinary health care team members in the care planning process for the patient -Document plan of care |
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Evaluation
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-Refer to established outcomes
-Evaluate individual’s condition and compare actual outcomes with expected outcomes -Summarize results of evaluation -Identify reasons for failure to achieve expected outcomes -Take corrective action to modify plan of care -Document evaluation in plan of care |
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Priority Problems Level
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-First-level priority Emergent, life threatening, and immediate
-Second-level priorityNext in urgency, requiring attention so as to avoid further deterioration -Third-level priorityImportant to patient’s health but can be addressed after more urgent problems are addressed -Collaborative problemsApproach to treatment involves multiple disciplines |
