Study sets, textbooks, questions
Upgrade to remove ads
Yoost Chapter 5: Introduction to the Nursing Process
Terms in this set (42)
the organized and ongoing appraisal of a ptient's well-being. Involves collecting data from a variety of sources that is needed to care for patients. Specific data collected during the patient interview, health history, and physical assessment. Assess also the state of the patient's physical, psychological, emotional, environmental, cultural and spiritual health to gain a better understanding of his or her overall condition.
care that promotes physical, emotional, social, intellectual, and spiritual well-being
the nurse prioritizes a patient's various nursing diagnoses, establishes short- and long-term goals, chooses outcome indicators, and identifies interventions to address patient goals. Emergent needs are dealt with first, then less critical problems take priority.
Short- and long-term goals
Must be patient focused, realistic, and measurable
focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment. not a record of the care that was implemented. Must clearly identify the effectiveness of implemented interventions with the patient as its focus.
focuses on initiation of appropriate interventions designed to meet the unique needs of each patient.
Interventions may be independent, dependent, or collaborative nursing actions requiring direct or indirect nursing care.
All derived from evidence-based practice standards that have evolved from research conducted to elicit the best patient outcomes possible.
clinical pathways (critical pathways)
case management tools used to communicate the standardized, interdisciplinary plan of care for a particular group of patients; care guidelines and outcomes are specified for each day of the patient's stay
written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physician's order. often included in the critical pathways
written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible or when care is common to a certain type of situation.
North American Nursing Diagnosis Association Internation, organized in 1973, which formally identifies, develops, and classifies nursing diagnoses for DOCUMENTATION, AUDITING, & COMMUNICATION purposes
Nursing diagnoses describe..
a response to an actual or potential problem or life process
as manifested by
Actual Nursing Diagnoses
P - problem or identified need of patient
E - the etiiology or underlying cause
S - signs and symptoms
Three types of nursing diagnoses
actual, risk, and health-promotion
Risk Nursing Diagnostic statement
1. Patient's identified need or problem.
2. Factors indicating vulnerability
Health-Promotion Nursing diagnostic statement
1. the nursing diagnostic label
2. defining characteristics
identifies an actual or potential problem or response to a problem
things a person tells you about that you cannot observe through your senses; symptoms. typically documented as direct quotations.
what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination
Nursing Diagnosis vs Medical Diagnosis
*Nursing Diagnosis: Focus on patient response & Identify potential problems
*Medical Diagnosis:Disease process
Primary emphasis on identifying
the current problem
*Both use physical assessment, interviewing and observing as ways
to derive the diagnosis
*Both are designed for planning patient care
Nursing Process Steps
the systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients
Effective use of the nursing process...
depends on a nurse's knowledge, familiarity with standardized nursing diagnosis terminology, evidence-based practice, and ability to evaluate patient responses to interventions
aspect of the nursing process, involves listing behaviors or observable items that indicate attainment of a goal.
Nursing outcomes classification is one resource for outcome identification
Nursing Interventions Classifications. Defines, and assists in choosing the appropriate nursing interventions for nurses, student nurses, administrators, and faculty
electronic medical record
Planning and Outcome Identification
Third step of the nursing process, during which goals/outcomes are determined and interventions chosen
The nurse develops a plan of care that prescribes strategies and alternatives to attain expected outcomes
Characteristics of the nursing process
analytical, dynamic, organized, outcome oriented, collaborative, adaptable
-Is the data collection thorough and accurate?
-Are outcomes specific and realistic for the individual patient?
-Have all of the underlying factors contributing to the patient's response to illness been adequately addressed in the plan of care?
-Could any of the nursing interventions have a negative impact on the patient?
-Does each intervention provide for patient-centered care and the safety of the patient?
-Are there new data that necessitate modification of the existing plan of care?
As evidenced by
I. Data collection:
a. Primary data
i. Patient interview
b. Secondary data
c. Subjective data
ii. Health History
d. Objective data
ii. Physical examination
iii. Laboratory results
iv. Diagnostic test results
I. Types of Nursing Diagnoses
I. Prioritize Nursing Diagnoses
II. Personalize Care Plans
a. Short-term goals (STGs)
b. Long-term goals (LTGs)
I. Nursing Outcomes Classification (NOC)
c. Collaborative Care
a. Nursing Interventions Classification (NIC)
III. Care Plans
a. Clinical pathways
c. Standing Orders
I. Care Plan Evaluation
a. Patient goal/outcome attainment?
The nursing process is analytical
Requires nursing to think analytically using many aspects of critical thinking. Must be able to assess patients accurately and then organize and analyze their findings to provide safe care.
The nursing process is dynamic
Changes over time in response to patient's individual needs. Allows the nursing process to be used effectively with patients in any setting and at every level of care.
The nursing process is organized
Thorough and systematic. The nursing process provides a standardized method of addressing patient needs that is understood by nurses worldwide.
The nursing process is outcome oriented
patient-centered nursing process is designed to achieve specific, well-defined outcomes. Patient care plans are developed to meet each patient's goals, not the goals of standardized patients or members of the health care team, including the nurse. Decisions made on the basis of safety and their effectiveness in meeting patient's needs.
The nursing process is collaborative
Collaboration among several members of the health care team is often required to address patient needs. Nurses may incorporate orders from a primary care provider and other health care team members into a patient's plan of care.
The nursing process is adaptable
Adaptable for developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting. Helpful for addressing the needs of a specific population.
Sets found in the same folder
Yoost Chapter 6: Assessment
Yoost Chapter 7: Nursing Diagnosis
Yoost Chapter 8: Planning
Yoost Chapter 27: Hygiene and Personal Care
Other sets by this creator
Giddens Professional Identity Concept 39 - well pu…
Giddens Concept 50: Health Care Quality
Yoost Chapter 13: Evidence-Based Practice and Nurs…
Yoost Chapter 13: Evidence-Based Practice and Nurs…
Recommended textbook solutions
Pharmacology and the Nursing Process
Julie S Snyder, Linda Lilley, Shelly Collins
The Human Body in Health and Disease
Gary A. Thibodeau, Kevin T. Patton
Clinical Reasoning Cases in Nursing
Julie S Snyder, Mariann M Harding
Medical Language for Modern Health Care
David M Allan, Rachel Basco