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17 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
Nursing Diagnosis Planning/Outcomes Implementation Evaluation |
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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,physical exam, and diagnostic studies.
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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, the client desires a higher level of wellness
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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)
Safety and security needs(2nd) Love and belonging needs(3rd) Esteem and self-esteem(4th) Self-actualization(5th) |
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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
defining expected outcomes determining specific interventions recording plan of care |
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Documentation serves 5 functions,they are:
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Communicates care
Shows trends and patterns in client status creates a legal document supplies validation for reimbursement Provides a foundation for evluation, research and quality improvement |
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Implementation
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carrying out the written plan of care, performing the interventions, onitoring the clients's status, and assessing and reassessing the client before,during and after treatment
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objective data
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what you observe,lab results,v/s,
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subjective data
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What the patient tells you he or she feels
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