HA

Nursing Process

A systematic, rational method of planning and providing individualized nursing care.

Phases of the Nursing Process

Six phases: Assessment, Diagnosis, Outcome identification, Planning, Implementation, Evaluation.

Assessment

Systematic and continuous collection, organization, validation, and documentation of data/information.

Primary Source of Data

The client is the primary source of data.

Secondary Source of Data

Family members, other health professionals, records, reports, and laboratory analysis serve as secondary sources.

Subjective Data

Data referred to as symptoms or covert data.

Objective Data

Data referred to as signs or overt data.

Cues

Subjective or objective data that can be directly observed by the nurse.

Inferences

The nurse's interpretation or conclusions made based on the cues.

Diagnosing

The second phase of the nursing process involving critical thinking to interpret assessment data.

Taxonomy

A classification system arranged based on principles.

Nursing Diagnosis

A clinical judgment concerning a human response to health conditions/life processes.

Actual Diagnosis

A client problem that is present at the time of the nursing assessment.

Health Promotion Diagnosis

Relates to client’s preparedness to implement behaviors to improve health.

Risk Nursing Diagnosis

A clinical judgment indicating that a problem is likely to develop unless intervened.

Syndrome Diagnosis

A cluster of nursing diagnoses with similar interventions.

Components of NANDA Nursing Diagnosis

Problem and definition, etiology, and defining characteristics.

Problem (Diagnostic Label)

Describes the client’s health problem or response for which nursing therapy is given.

Etiology

Identifies one or more probable causes of the health problem.

Defining Characteristics

Cluster of signs and symptoms indicating the presence of a particular diagnosis.

Nursing Diagnosis vs. Medical Diagnosis

Nursing Diagnosis refers to human responses that nurses can treat, while Medical Diagnosis refers to conditions treated by physicians.

Collaborative Problems

Potential problems managed using both independent and physician-prescribed interventions.

Planning Phase

A systematic process involving decision-making and problem-solving.

Initial Planning

The nurse develops the initial comprehensive plan of care during the admission assessment.

Ongoing Planning

All nurses contribute to ongoing planning based on evaluation and new information.

Discharge Planning

Planning for client needs post-discharge as part of comprehensive healthcare.

Formal Nursing Care Plan

A written guide organizing information about a client’s care.

Individualized Care Plan

Tailored to meet the unique needs of a specific client.

Assessment of Vital Signs

Include measuring temperature, pulse, respiration, and blood pressure.

Core Temperature

Temperature of deep tissues such as the abdominal cavity.

Surface Temperature

Temperature of the skin and subcutaneous tissues.

Factors Affecting Body Temperature

Include Basal Metabolic Rate, muscle activity, stress response, and fever.

Methods of Heat Loss

Radiation, conduction, convection, and vaporization.

Types of Thermometers

Mercury-in-glass, electronic, and disposable thermometers.

Normal Body Temperature Range

36º C to 37º C (96.8 º F to 98.6 º F).

Fever

Body temperature above normal, categorized into low-grade and high-grade fever.

Pulse Rate

The measurement of heart rate, or the number of heart contractions per minute.

Factors Affecting Pulse Rate

Include age, gender, exercise, fever, medications, and stress.

Types of Pulse

Include temporal, carotid, apical, brachial, radial, femoral, popliteal, posterior tibial, and pedal.

Assessment of Pulse Rate

Consider rate, rhythm, volume, and elasticity of the arterial wall.

Respiration

The act of breathing, which includes inhalation and exhalation.

Types of Breathing

Costal (thoracic) and diaphragmatic (abdominal) breathing.

Factors Affecting Respiration

Including exercise, pain, anxiety, smoking, body position, and medications.

Assessment of Respiration

Includes assessing the rate, depth, rhythm, and quality of breathing.

Blood Pressure (BP)

Measurement of the pressure exerted by blood on arterial walls.

Systolic Pressure

The highest blood pressure during heart contraction.

Diastolic Pressure

The lowest blood pressure during heart relaxation.

Hypertension

High blood pressure, sustained systolic BP of 140 mm Hg or greater.

Hypotension

Low blood pressure, measured as less than 95/60 mm Hg.

Pulse Pressure

The difference between systolic and diastolic pressures.

Factors Affecting Blood Pressure

Include age, gender, emotional states, and body position.

Manual Blood Pressure Measurement Equipment

Includes a stethoscope and sphygmomanometer.

Nursing Interventions

Treatments based on clinical judgment to enhance patient outcomes.

Setting Priorities

Establishing a preferential sequence for addressing nursing diagnoses.

Establishing Client Goals

Setting desired outcomes for each nursing diagnosis.

Selecting Nursing Interventions

Interventions that focus on the etiology of nursing diagnosis.

Writing Individualized Nursing Interventions

Documenting chosen nursing interventions on the care plan.

Implementation Phase

The action phase where nursing interventions are performed.

Reassessing the Client

A critical step during the implementation phase.

Supervising Delegated Care

Nurse's responsibility for overall client care after delegation.

Documenting Nursing Activities

Recording interventions and client responses in progress notes.

Evaluation

Assessing client progress towards goals and effectiveness of the nursing care plan.

Normalization of Vital Signs

Monitoring and maintaining a stable physiological status.

Understanding Vital Signs

Reflects the body's current condition or health state.

Continuous Data Collection

The systematic and ongoing process needed for accurate health assessment.

Effective Communication in Nursing

Essential for gathering accurate data during assessment.

Types of Interview Questions

Closed, open-ended, and neutral questions for client interaction.

Clinical Judgement in Nursing

Utilizing skills to make informed decisions in patient care.

Documentation in Nursing

Recording accurate, factual information about client health status.

Nursing Diagnosis

A clinical judgment concerning a human response to health conditions/life processes.

What is the Nursing Process?

A systematic, rational method of planning and providing individualized nursing care.

What are the phases of the Nursing Process?

There are six phases: Assessment, Diagnosis, Outcome identification, Planning, Implementation, and Evaluation.

Critical Thinking in Nursing

The ability to analyze and evaluate information to make informed patient care decisions.

Patient-Centered Care

Healthcare approach that respects and responds to individual patient preferences, needs, and values.

Evidence-Based Practice

Integrating clinical expertise with the best available research and patient values to inform care.

Informed Consent

A process ensuring patients understand their treatment options and give voluntary permission for procedures.

Advocacy in Nursing

Support and defend the rights and interests of patients within the healthcare system.

Holistic Care

Care that addresses the physical, emotional, social, and spiritual needs of patients.

Multidisciplinary Team

A group of healthcare professionals from various specialties collaborating to provide comprehensive care.

Care Planning

The process of developing a detailed outline of nursing care and interventions for a patient.

Discharge Instructions

Guidelines provided to patients when leaving the healthcare facility to ensure proper post-discharge care.

Patient Safety

Measures and practices designed to prevent harm to patients and reduce medical errors.

Nursing Care Plan

A formal written guide that organizes information about a patient's nursing care.

Individualized Care

Care tailored specifically to meet the unique needs and preferences of an individual patient.

Clinical Judgement

The process of using critical thinking skills to make decisions about patient care.

Compassionate Care

Care provided with empathy and concern for a patient's emotional and psychological needs.

Patient Education

The process of educating patients about their health conditions, treatments, and self-care strategies.

Interdisciplinary Collaboration

Cooperative efforts among healthcare professionals to provide comprehensive patient care.

Nursing Ethics

Moral principles that guide nursing practice and decision-making.

Quality Improvement

Ongoing efforts to improve patient care processes and outcomes.

Preventive Care

Healthcare services aimed at preventing diseases and promoting overall health.

Culturally Competent Care

Healthcare that recognizes and respects the diverse cultural backgrounds of patients.