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22 Cards in this Set

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Nursing Process is ______ and _______

Dynamic and Continuous
Using Critical Thinking in the Nursing Process
-Recognizing an issue exists (patient problem)

-Analyzing information about the issue (data)


-Using information (knowledge, experience, standards, attitudes) to evaluate the issue


-Making a conclusion

Primary Source

Patient

Secondary

Family, physician, etc.

Subjective Data

Patient


Interview and Health History

Objective Data

Physician


Open ended questions


-Physical Exam


-Diagnostic and Lab Data

Skin is cool and damp, what type of data is this?

Objective

Usually voids two times during the night, what type of data is this?

Subjective

Analysis and Interpretation of Data


Clustering

Take all of the information given from patient and place them according to system (cardio, pulmonary, etc.)

Medical Diagnosis VS. Nursing Diagnosis

Medical (Physician) treats the disease, nursing diagnosis deals with patients response to the disease.

NANDA

North American Nursing Diagnosis Association

Collaborative Problem

When nurses and doctors work together to prevent the disease process from occurring. Sometimes make protocols for specific medical diagnosis.

The nursing diagnostic process is ________

Decision making steps

Different types of nursing diagnosis

Actual nursing diagnosis


Risk nursing diagnosis


Health promotion diagnosis - acknowledges a certain type of lifestyle or action that can cause future problems to patient or community such as not receiving a flu shot.

Nursing Process


Format- PES

Problem (NANDA)- Activity intolerance


Etiology (related factor)- related to bed rest


Symptom (defining characteristic)- patient reports fatigue and weakness

Types of Nursing Interventions

Independent: Nurse-initiated interventions

Dependent: Physician-initiated interventions


Interdependent: Collaborative interventions

Discharge Planning is planned _______

The day the patient is admitted. Any education needs?

Nursing Care Plan

Plan made my head nurse of patient and carried out by all nurses who care for patient.

Nurses should never delegate _____?

Assessment unless it is to another nurse

Nursing Process


Evaluation

To see if goals have been met.


-Goals have been met.


-Goals have been partially met.


-Goals have not been met.

If goal has not been met?

Start over with assessment and the care plan (thats why the process is continuous).

Critical Pathways

Allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for patients.