2. Caring Skills
3. Counseling Skills
4. Comforting Skills
perceive clients emotional state and support and must be detached.
Feeling emotionally distraught as the client
an organized sequence of problem solving steps used to identify and manage health problems.
Must be in the legal scope of nursing
Based on Knowledge - Requires Critical Thinking
Planned: Organized and systematic
Client Centered - Advocate - Patient has to be part of it.
Goal Directed - Has to be reasonable
Prioritized - Maslow - what's most important
Dynamic - Constantly Changing
LPN's and RN's have different responsibilities related to the nursing process but the RN still responsible for data collection.
Only information clients feels and describes ex: pain, nausea, dizzy, constipation
Observable and measurable fact ex: Weight, BP, pulse, respirations
Primary Source: Patient
Secondary Source: Family, reports, test results
Data Base Assessment
Comprehensive. Obtained at admission and physical exam.
Specific, expanded information. Focus on one specific area of speciality
A health issue that can be prevented, reduced, resolved or enhanced through independent nursing measures.
North American Nursing Diagnosis Association
Name of health related issues or problems as identified in the NANDA list.
Prioritizing nursing diagnosis.
Collaborative problems with others
Measurable goals with the patient
Short Term Goal
A few days to a week and must have a target date
Long Term Goal
Weeks or months
Directions for a clients care
Standards of Care
Policies that indicate which activities will be provided to ensure quality client care
Carrying out the plan of care
The way in which nurses determine whether a client has reached a goal.
A method of organizing information into graphics or pictorial form.