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Systematic, rational method of planning and providing nursing care The Nursing Process Goal of the nursing process is... to identify a clients health status, health care problems (or those at risk for), est. plans to meet identified needs, and to deliver specific nursing interventions to meet those needs The Nursing Process is essential to... safe, competent, skillful nursing practice The NP is a method for... organizing and delivering nursing care NP characteristics are.. planned, client-centered, problem-oriented, and goal-directed Six steps of the NP are... 1. Assessment 2. Diagnosis 3. Outcomes Identification 4. Planning 5. Implementation 6. Evaluation Establishes client's data base ex. "What's bothering the pt. THAT day" Assessment Identifies client's health care needs Diagnosis Determines priorities of care and goals and expected outcomes. Ex. start to figure out what you want to happen. Outcome Identification Create a plan of care Planning Enact the created plan of care. Ex. start doing Implementation Determine the effectiveness of nursing care in achieving goals Evaluation Assessment data collection that can be detected by the observer, measured verified, or tested; seen, heard, felt, smelled (ex. b/p, crying, rash), obtained by observation or physical exam; "signs" or overt data Objective Assessment data collected that is apparent only to the affected person, verified or described by that person only, are opinions/feelings (ex. pain, itching, worry, grief), "symptoms" or covert data Subjective Assessment data must be... complete, accurate, factual, without judgment A pt. says their pain is "8 out of 10", the data is considered... SUBJECTIVE Best source of assessment data is... CLIENT Sources of assessment data... Client, support people (family), Client records (if name is known), Health Care professionals, Literature Primary--Direct Source Assessment data collection is... provided by the client; the best source of data unless pt. is ill, young, or confused Secondary--Indirect Source Assessment data collection is.... provided by family, friends, caregivers, client records, health care professionals, and literature Problems with data collection are.. Pt's LOC, no family/caregiver available, gaps in data (discrepancies and inconsistencies) Assessment data collection methods: Observations, Interviews, Exams Posture, Breathing, and speaking are examples of what data collection method? Observation Histories are an example of what data collection method? Interviewing In depth observation ex. Auscultation is an example of what data collection method? Examining Nurse uses critical thinking to interpret assessment data and identify clients strength's and problems Diagnosis Reflects clinical judgment about responses to actual and potential health problems Diagnosis Components of Nursing Diagnosis are... Problem statement, Etiology, and Defining Characteristics Describes client's Health Problem (directs clients goals and outcomes) Problem Statement Identifies one or more probable causes of a health problem. Etiology Signs and symptoms that indicate presence of a problem. (How do you know?) Defining Characteristics Pain r/t inflammation AEB pt. states pain "7 out of 10". What is Pain? Problem Statement bc it directs goals and outcomes Pain r/t inflammation AEB pt. states pain "7 out of 10". What is Inflammation? Etiology bc it is the cause of pain and it directs interventions. Pain r/t inflammation AEB pt. states pain "7 out of 10". What is AEB pt. states pain "7 out of 10"? Defining characteristics bc it is how we know the pt. is in pain. Another word for DIAGNOSING. Compares data to standards. Identifies gaps and inconsistencies. Ns. and Pt. can together identify problems and support diagnosis. Analyzing Data Three steps of planning are: Initial, Ongoing, and Discharge Initial planning is done... right when meeting the pt. Discharge planning is done... when you first meet the pt. A goal is... A broad statement. Statements that describe specific, observable, ad measurable responses and can be long-term or short-term are... Outcomes Nusing interventions are derived from which part of the nursing diagnosis? The etiology Phase where the nurse implements nursing interventions. Needs cognitive, interpersonal, and technical skills. Implementation Types of Implementation are... Collaborative, Independent, Dependent, and Protocols. Working with someone (HCP) on something you need help with is what type of implementation? Collaborative Something YOU can determine to do as a nurse is what type of implementation? Independent Is determined by the doctor ex. diets and IV's are what type of implementation? Dependent Prewritten orders that stand are what type of implementation? Protocols What is the implementation process? 1. Reassessing 2. Determining need for nursing assistance 3. Implementing nursing interventions 4. Supervising delegated care 5. Documenting To judge or appraise. Ns. and pt. determine progress toward achievement of goals. Determines if interventions should be terminated, continued, or changed. Evaluation Steps in Evaluation are... 1. Collect Data 2. Compare data with outcomes 3. Relate nursing activities to outcomes 4. Draw conclusions about problem 5. Continue, modify, or terminate care plan Goal outcome is always written... PT. specific and from the pt's point of view Very specific about actions Nursing order An essential attribute of professional nursing practice... Communication A level of communication that is one on one interaction between two people is... Interpersonal A level of communication that occurs within an individual is.. Intrapersonal A level of communication that is the interaction with an audience is... Public A level of communication that is the interaction within a person's spiritual domain is... Transpersonal A level of communication that is the interactions with a small number of people is... Small group Verbal communication deals with... spoken and written words Personal apperance, posture, gait, facial expressions, eye contact, gestures, sounds, territoriality, and personal space are all examples of... Nonverbal Communication Nonverbal Communication involves... senses 4 phases of Nurse-Client relationships are.. 1. Preinteraction 2. Orientation (when meeting the pt.) 3. Working (Work w. pt. to solve problems & goals) 4. Termination (at discharge or death) Safe basic human needs include... Oxygen, nutrition, temperature, and humidity