The Nursing Process

Front 1

Nursing Process definition

Back 1

a step-by-step method of providing care to clients

Front 2

5 parts to the Nursing Process

Back 2

assessment, diagnosis, planning and outcome identification, implementation, and evaluation

Front 3

Process

Back 3

a series of planned actions or operations directed toward a particular result or goal

Front 4

Care plan

Back 4

documentation of the first, second, and third steps of the nursing process

Front 5

Collaboration

Back 5

communication with other disciplines to solve problems

Front 6

Step 1: Assessment- (definition and 5 steps)

Back 6

-provides significant information, assembled to form the client database
-Data collection, Verification, Organization, Interpretation, and Documentation

Front 7

Objective Data

Back 7

observable or measureable information, accumulated through the physical exam, interview, or results of diagnostic examinations

Front 8

Subjective Data

Back 8

the client's communicated description, perception, feelings, emotions, or concerns.

Front 9

Step 2:Diagnosis-

Back 9

the classification of a disease, condition, or human response based upon scientific evaluation of signs and symptoms, patient history, and diagnostic studies

Front 10

Actual Nursing Diagnosis
(an actual problem exists)

Back 10

When the client demonstrates signs and symptoms

Front 11

Medical Diagnosis

Back 11

determined by the physician or nurse practitioner indicating a disease or disorder identified or to be ruled out. Pneumonia, renal failure, sepsis, or diabetes mellitus

Front 12

Nursing Diagnosis

Back 12

a clinical judgement about individual, family, or community responses to actual or potential helth problems/life process.

Front 13

Step 3:Planing and outcome indentification. 3 steps.

Back 13

1. Prioritizing nursing diagnosis
2. Identifying short and long term goals and expected outcomes
3. Determining nursing interventions that will aid in resolution or prevention of each problem

Front 14

Nursing interventions

Back 14

activities executed to enable accomplishment of goals

Front 15

Step 4: Implementation

Back 15

involves execution of the nursing care plan
1. activating the care plan
2. carrying out planned interventions
3. continued assessment as interventions are carried out
4. Recording and documenting care provided, interventions carried out, and client responses

Front 16

Step 5:Evaluation

Back 16

-appraisal of results
-the nurse determines if the client goals were met, partially met, or not met.

Front 17

Critical Thinking

Back 17

a purposeful thought process incorporating various strategies in search for the meaning of data

Front 18

Baseline Data

Back 18

initial data collected become the foundation of the client database

Front 19

Data Clustering

Back 19

the process of organizing subjective and objective data into groups of related cues.

Front 20

Risk nursing diagnosis

Back 20

possible developing problems resulting from a client's physical, sociocultural, psychological, and/or spiritual illness, disease, or condition

Front 21

Problem

Back 21

the identified label of a client's health condition or response to the medical illness or therapy for which nursing may intervene.

Front 22

Etiology

Back 22

written, "as related to" (R/T) includes conditions most likely to be involved in the development of a problem

Front 23

Defining characteristics

Back 23

written, "as evidenced by" (AEB) are the clinical signs and symptoms which confirm the problem exists

Front 24

Wellness Diagnosis

Back 24

a clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness

Front 25

Expected outcome

Back 25

describes the methods through which the goal will be achieved