Nursing Process
About this set
Created by:
ambrown01 on September 24, 2012
Subjects:
Description:
Fundamentals of Nursing
Classes:
NUR1055 Adult Health I, JJC Nursing 150, 140, Pharmacology Spring 2013
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41 terms
Terms | Definitions |
|---|---|
 first step in the NP | assess |
| second step in the NP | diagnose |
| third step in the NP | plan 1. goals, outcomes 2. interventions |
| fourth step in the NP | implement |
| fifth step in the NP | evaluate |
| Nursing process | systematic rational method of planning and providing nursing care |
| Goal of Nursing Process | identify clients health status actual or potential health care problems establish plans to meet the identified needs deliver specific nursing interventions to meet those needs |
| medical process | focuses on the disease |
| goal of assessment | identify clients nursing care needs |
| the four types of assessment | initial emergency problem- focused time- lapsed |
| Types of data | objective : what you observed subjective: what they tell you |
| The Client | is the Primary source of Data |
| Secondary Sources of Dat | health personnel literature old records/charts |
| Methods of Data Collection | Interviewing ( directive and nondirective) and Examining |
| diagnosis | a clinical judgement about individual family or community responses to actual and potential health problems/ life processes |
| Nursing Diagnoses | provide the basis for selection of nursing interventions achieve outcomes for which the nurse is accountable |
| Types of Nursing Diagnoses | health problems health promotion risk wellness syndrome |
| First step in DP | physiologic needs |
| Second step in dp | safety and security |
| third step in dp | love and belonging |
| fourth step in dp | self esteem |
| fifth step in dp | self actualization |
| cue | a piece of information that influences decisions |
| etiology | one or more probable causes of the health problems |
| diagnostic statement | the 2 or 3 part problem and etiology joint by the r/t and manifested by |
| planning | process of designing the nursing strategies or interventions required to prevent, reduce, or eliminate |
| factors related to priority setting | client values and beliefs resources available to the nurse and client including time urgency of the problem medical treatment plan |
| goal | desired outcome or change in client behavior in the direction of health |
| outcome | result of an activity rather than the activity itself |
| nursing interventions and nursing orders | should include: date action verb content area time element signature |
| nursing order | observation prevention treatment health promotion |
| concept map care plan | focuses on the actions nurses must take to address the clients needs and meet stated goals |
| discharge planning | anticipating and planning for needs after discharge from the hospital or other facility |
| implementing | putting the care plan in action ( carrying out nursing and physician orders) |
| types of nursing actions | independent ( nurses own knowledge and skills) dependent ( carried out on doctors order or nurse practitioner) collaborative ( performed jointly with another member of a HC team ) |
| protocol | written plan specifying the procedure to be followed in a particular situation |
| standing order | written document about policies, rules, regulations, or orders regarding client care |
| process of implementing | reassess the client continue to collect data never assume that nursing interventions must be implemented |
| evaluating | identify whether or to what degree the clients goals have been met |
| 3 possible evaluation outcomes | goal was met goal partially met goal not met |
| evaluation process | collect data compare data with outcomes relate nursing activities to outcomes draw conclusions about problem status continue with modifying or terminating the nurse plan |
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