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18 Cards in this Set
- Front
- Back
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Nursing process
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a systematic method for nurses to plan and implement client care to achieve desired outcomes
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5 steps of nursing process
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Assessment
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Assessment
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the careful observation and evaluation of a client's health status
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Client database
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all the information obtained from the medical and nursing history
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Actual diagnosis
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A problem that already exists
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Risk diagnosis
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A problem that the client is at high risk for developing
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Possible diagnosis
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a problem that is suspected but more data are needed before making a decision
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Collaborative problem
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a problem tat is monitored and managed by the the nurse using physician-prescribed and nursing-prescribed interventions
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Wellness diagnosis
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No problem exists
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Syndrome diagnosis
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Used when the diagnosis is associated with a cluster of other diagnoses
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Establishing Priorities(planning)
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Physiologic needs(1st level)
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who developed Hierarchy of human needs
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Maslow
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Step in Planning
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setting priorities
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Documentation serves 5 functions
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they are:
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Provides a foundation for evluation
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research and quality improvement
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Implementation
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carrying out the written plan of care
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objective data
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what you observe
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subjective data
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What the patient tells you he or she feels
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