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24 Cards in this Set

  • Front
  • Back

Analysis

Using data to determine patient need for nursing diagnosis

Assessment

Collection of subjective and objective data

Evaluation

Decision making process determining the effectiveness of nursing actions or interventions

Expected outcome

Expected behavior and physical and mental state of the patient after a therapeutic intervention

Implementation

Carrying out of a plan of action

Independent nursing actions

Actions that do not require a physician's order

Initial assessment

Gathering of baseline data

Nursing diagnosis

Description of a patient problem

Nursing process

Framework for nursing action consisting of a series of problem solving steps which helps members of the healthcare team provide effective and constant patient care

Objective data

Information obtained through a physical assessment or physical examination lab test or scans

Ongoing assessment

Continuing assessment activities that proceed from the initial nursing assessment

Planning

Design of steps to carry out nursing actions

Subjective data

Information supplied by the patient or family

The five phases of the nursing process

Assessment,analysis (nursing diagnosis ) ,planning, implementation , and evaluation

What the assessment involves

Assessment involve collecting objective and subjective data

When is an initial assessment made

When the patient is first seen in the hospital

Important objective data

Blood pressure, pulse, respiratory rate, temperature, weight, appearance of the skin

Important subjective data

Relief or non relief of pain or other symptoms

NANDA

Organization that approves and standardize nursing diagnosis

The most frequently used nursing diagnoses are

Effective self health management, ineffective self health management, deficient knowledge, non-compliance, anxiety

What do you do after nursing diagnosis

Formulate a patient oriented goals and expected outcomes are developed

What does the expected outcome describe

The maximum level of wellness that is responsibly attainable the patient

What are the expected patient outcomes

Effectively manage the drug regimen

Dependent nursing

You need an order to do it