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30 Cards in this Set
- Front
- Back
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What is the nursing process?
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professional nurses' approach to identify, diagnose, and treat human responses to health and illness.
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What are the five steps to the nursing process?
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1. Assessment
2. Diagnosis 3. Planning 4. Implementation 5. Evaluation |
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What is included in the assessment step of the nursing process? (2 steps)
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*Collection & verification of data from primary & secondary sources.
*analysis of data as a basis for developing a nursing diagnosis, identify collaborative problems & developing a plan of care. |
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What is the purpose of the assessment?
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Establish a database about the client's perceived needs, health problems, and responses to these problems.
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What is the diagnosis part of the nursing assessment?
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*classifies health problems within the domain of nursing.
* a clinical judgement about individual, family, or community responses to actual and potential health problems or life process. *provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is held accountable. |
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What is involved in the planning step of the nursing process?
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* nurses set client-centered goals & expected outcomes
*plan nursing interventions *requires critical thinking applied through delibrate decision making & problem solving. |
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What is involved in the evaluation portion of the nursing process?
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*determine if the clients ondition or well being improves after implementation of the nursing process.
*nurses conduct evaulative measures to determine if expected outcomes were met *not to determine if nursing interventions were completed. |
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What is objective data?
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*information that can be validated using 5 senses
*observations or measurements of client's health staus *ie: inspection of a wound, description of an observed behavior, measurement of BP *can only document objective data |
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What is subjective data?
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*can't be validated with 5 senses
*ie: clients verbal descriptions of their health problems *include feelings, perceptions, & self-report symptoms |
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What is a cue?
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*similar to objective data
*info you obtain using 5 senses |
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What is an inference?
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*judgement or interpretation of cues
*nurses perpective from cues |
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How should the nurse create client goals?
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*should reflect resolution of problem
*evidence of progress toward resolution of problem *maintenance of current health *progress toward improved health |
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What characteristics should goals have?
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*goals and outcomes need to meet established intellectual standards by being relevant to client needs, specific, singular, observable, measurable, and time-limited.
*Help us evaluate the effectiveness of our plan |
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What should be included in nursing documentation?
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Factual, accurate, complete, current, and organized information
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What does information in a client record provide?
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*detailed account of the leel of quality of care delivered to clients.
*ensures continuity of care, saves time and minimizes the risk for errors |
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how should reflection be used in an interview?
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clarification, reflect back what the client has provided
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Why is active listening important?
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*Makes sure you have adequate and appropriate information
*hear and take in what client is telling you before you reply; silence is okay* |
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Why do we need to use a consistent set of language?
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*consistent language fosters better communication, better understanding, allows us to find research, provides for payment
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Five types of diagnosis
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1. Actual
2. Risk 3. Syndrome 4. Wellness 5. Possible |
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How is an acutual diagnosis put together?
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Label+related to+ Contributing Factors (etiology)+as evidenced by+Defining Characteristics (signs and symptoms you have from assessment)
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How is a Risk diagnosis put together?
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Risk for+Label+related to+ Risk Factors (what makes them at risk?)
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How is a Syndrome diagnosis put together?
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Label Syndrome
(not used very often) |
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How is a Wellness diagnosis put together?
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potential for enhanced +Label
(used for someone who is well, but could be even better |
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How do you put a Possible diagnosis together?
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possible+Label+related to + why you suspect the diagnosis might be present
(need further information, usually use this along the way before you get to writing your care plan) |
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What two characteristics contribute to the "related to" factors?
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1. Major Defining Characteristics- things that must be valid for the diagnostic label to be present
2. Minor Defining Characteristics- may be present for the label to be present, but doesn't have to be |
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Errors made in writing diagnosis
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*inaccurate data
*making legally inadvisable statements *inadequate validation *incorrect or omitted related factors |
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Four components of Goal Statement
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1. Individual/Family (what the client will do)
2. Will (achievement) as evidenced by... 3. (qualifiers: how, what, where, and under what circumstances 4. by (time frame) |
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Goal of an Actual diagnosis
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Client will demostrate/report that the problem is resolved or decreased
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Goal of Risk diagnosis
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The client will demostrate/report continued health status or no evidence of the problem actually occuring
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Goal of Wellness Diagnosis
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Client will demostrate or report a higher level of health
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