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24 Cards in this Set
- Front
- Back
Analysis |
Using data to determine patient need for nursing diagnosis |
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Assessment |
Collection of subjective and objective data |
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Evaluation |
Decision making process determining the effectiveness of nursing actions or interventions |
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Expected outcome |
Expected behavior and physical and mental state of the patient after a therapeutic intervention |
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Implementation |
Carrying out of a plan of action |
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Independent nursing actions |
Actions that do not require a physician's order |
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Initial assessment |
Gathering of baseline data |
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Nursing diagnosis |
Description of a patient problem |
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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 |
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Objective data |
Information obtained through a physical assessment or physical examination lab test or scans |
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Ongoing assessment |
Continuing assessment activities that proceed from the initial nursing assessment |
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Planning |
Design of steps to carry out nursing actions |
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Subjective data |
Information supplied by the patient or family |
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The five phases of the nursing process |
Assessment,analysis (nursing diagnosis ) ,planning, implementation , and evaluation |
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What the assessment involves |
Assessment involve collecting objective and subjective data |
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When is an initial assessment made |
When the patient is first seen in the hospital |
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Important objective data |
Blood pressure, pulse, respiratory rate, temperature, weight, appearance of the skin |
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Important subjective data |
Relief or non relief of pain or other symptoms |
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NANDA |
Organization that approves and standardize nursing diagnosis |
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The most frequently used nursing diagnoses are |
Effective self health management, ineffective self health management, deficient knowledge, non-compliance, anxiety |
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What do you do after nursing diagnosis |
Formulate a patient oriented goals and expected outcomes are developed |
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What does the expected outcome describe |
The maximum level of wellness that is responsibly attainable the patient |
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What are the expected patient outcomes |
Effectively manage the drug regimen |
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Dependent nursing |
You need an order to do it |