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25 Cards in this Set
- Front
- Back
Nursing Process definition
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a step-by-step method of providing care to clients
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5 parts to the Nursing Process
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assessment, diagnosis, planning and outcome identification, implementation, and evaluation
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Process
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a series of planned actions or operations directed toward a particular result or goal
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Care plan
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documentation of the first, second, and third steps of the nursing process
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Collaboration
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communication with other disciplines to solve problems
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Step 1: Assessment- (definition and 5 steps)
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-provides significant information, assembled to form the client database
-Data collection, Verification, Organization, Interpretation, and Documentation |
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Objective Data
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observable or measureable information, accumulated through the physical exam, interview, or results of diagnostic examinations
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Subjective Data
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the client's communicated description, perception, feelings, emotions, or concerns.
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Step 2:Diagnosis-
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the classification of a disease, condition, or human response based upon scientific evaluation of signs and symptoms, patient history, and diagnostic studies
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Actual Nursing Diagnosis
(an actual problem exists) |
When the client demonstrates signs and symptoms
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Medical Diagnosis
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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
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Nursing Diagnosis
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a clinical judgement about individual, family, or community responses to actual or potential helth problems/life process.
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Step 3:Planing and outcome indentification. 3 steps.
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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 |
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Nursing interventions
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activities executed to enable accomplishment of goals
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Step 4: Implementation
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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 |
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Step 5:Evaluation
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-appraisal of results
-the nurse determines if the client goals were met, partially met, or not met. |
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Critical Thinking
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a purposeful thought process incorporating various strategies in search for the meaning of data
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Baseline Data
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initial data collected become the foundation of the client database
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Data Clustering
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the process of organizing subjective and objective data into groups of related cues.
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Risk nursing diagnosis
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possible developing problems resulting from a client's physical, sociocultural, psychological, and/or spiritual illness, disease, or condition
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Problem
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the identified label of a client's health condition or response to the medical illness or therapy for which nursing may intervene.
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Etiology
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written, "as related to" (R/T) includes conditions most likely to be involved in the development of a problem
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Defining characteristics
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written, "as evidenced by" (AEB) are the clinical signs and symptoms which confirm the problem exists
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Wellness Diagnosis
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a clinical judgement about an individual, family, or community in transition from a specific level of wellness to a higher level of wellness
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Expected outcome
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describes the methods through which the goal will be achieved
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