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56 Cards in this Set
- Front
- Back
Components of the Nursing Process: (Foundation) |
*Systematic problem-solving approach toward giving individualized nursing care |
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Components of the Nursing Process:(Foundation) |
*Framework for prividing nursing care to indiv., families, and communities |
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Components of the Nursing Process:(Foundation) |
Each Phase of the nursing process interacts with and is influences by other phases. |
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Theorectical Foundations |
Systems Theory |
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Assessment |
Systematic collection of subjective and objective data with the goal of amiing a clinical nursing judgment about an individual, family or community |
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Assessment is done for the following reasons |
*To establish baseline information on the client |
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When is Assessment Done |
Before development of a plan of care |
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Types of Assessments |
Initial Assessment |
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Initial Assessment |
-also known as admission assessment |
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Focus Assessment |
*Collect data about a problem that has already been identified |
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Time Lapsed Reassessment |
*Comparison of client's current status to baseline (i.e. initial assessment) obtained previously |
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Emergency Assessment |
Identification of life-threatening situation 9i.e, physiologic, psychological, or emotional crisis) |
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Assessment Skills (Observation) |
-begins the moment the nurse meets the client |
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Assessment Skills |
*Involves effective communication techniques |
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Assessment Skills |
Four techniques: |
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Assessment Skills |
Use of linsight, instincts, or clinical experience to make judgements aobut a client care 9i.e., common sense, gut feeling, or a sixtth sense) |
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Assessment Activities |
Subjective (covert=non-observable) |
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Assessment Activities |
Primary Source |
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Nursing Diagnosis |
"clinical judgement about individual, family or community responses to actual or ptential health/life processes that the nurse is licensed and comptetent to treat. It provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" |
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Nursing Diagnosis (2) |
This is the 2nd phasse of the nursing process that enables the nurse to individualize care for the client. |
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The Nursing Diagnosis Statement |
The etiology of the nursing diagnosis must be within the domain of nursing practice an a condition that responds to nursing interventions |
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Medical Diagnosis vs. Nursing Diagnosis |
Nursing diagnosis |
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Components of a Nursing Diagnosis |
**Diagnostic label (definition) |
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Types of Nursing Diagnosis |
Describres a human respon to a health problem that is being manifested. |
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Types of Nursing Diagnosis |
Describes human responses to health conditions/life processes tht may develop in a vulnerable individual, or community |
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Types of Nursing Diagnosis |
Diagnostic statement that describes the human responses to levels of wellness. |
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Types of Nursing Diagnosis |
Made when not enough evidence supports the presence of the problem |
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Outcome Identification |
Refers to formulating and documenting measurable, realistic, client-focused, goals and expected outcomes and nursing interventions are selected to achieve the goals and outcomes of care |
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Outcome Identification seves the following purposes |
-providing individualized care |
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Outcome Identification Activities |
Priority selection is the method the nurse and client use to mutually rank th diagnoses in order of importance based on the client's desires, needs and safety |
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Outcome Identification Activities |
-life threatening situations |
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Outcome Identification Activities |
-problems that might result in unhealthy consequences but are not life threatening i.e. dysfunctional grieving fatigue, stress incontinence |
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Outcome Identification Activities |
-problems that can be resolved easily with minimal intervention |
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Client Outcome & Outcome Criteria |
- a client outcome is an eduated guesss, about what the client's state will be after the nursing intervention is carried out |
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Planning |
The nursing plan of care is a written summary of the care that a client is to receive and JCAHO requires a written plan of care for each client |
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Purposes of planning include the following |
-direct client care activities |
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Planning nursing interventions |
-actions designed to assist the client in moving from the present level of health to that which is describled in the goal and measured in the outcome |
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Implementation |
*Category of nursing behaviors in which actions necessary for achieving the goals and expected outcomes of nursing care are initiated and completed. |
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Implementation Includes |
-providing direct care to achieve cleint centered goals |
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Implementation skills |
*Intellectual skills |
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Implementation Activities |
*Reassessment |
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Implementation Types |
Dependent |
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Implementation of Nursing Intervention |
*Nurse initiated: |
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Cognitive Interventions |
Education (demonstrating, teaching, observing returen demonstrations) |
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Interpersonal Interventions |
Coordinating (Involves acting as a client advocate, making referrals for folloup care, collaborating with other healthcare team members) |
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Technical Interventions |
Maintence (retain a certain state of health, preventing deterioration of physical or psychological functiong and preserving independence) |
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Physician Initiated Intervention |
Based on physician's response to a medical diagnosis |
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Evaluation |
Step in the nursing process that measures the client's response to nursing actions and the client's progress toward achieving goals |
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Types of Evaluation |
Structure Evaluation |
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Structue Evaluation |
Focuses on the atttrivutes of the setting or surrounding where healthcare is provided |
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Process Evaluation |
Focuses on the nurses' performance and whether the nursing care provided was appropriate and competent |
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Outcome Evaluation |
Determins the extent to which the client's behavioral response to nursing interventions reflects the desired client goal and outcoem criteria i.e standards of care |
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Types of Interventions |
Cognitive, Interpersonal, Technical, Physician Initiated |
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Purposes for carrying out Evaluation |
-To examine the client's behavioral resonses to nursing interventions |
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Evaluation Activities |
-Review client goals and outcome criteria |
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Evaluation Skills |
-Knowlege of standard of care |