Nursing Process

Flashcards related to the nursing process and its application to patient care.

Nursing Process

Guides clinical judgement, decision making, and reflective nursing practice when used in the manner that encourages critical thinking in each of the steps.

Nursing Process

A systematic and rational method of planning and providing patient care organized around a series of phases that facilitates evidence-informed, and ethical practice.

Nursing Process

A problem-solving method and a framework for providing professional quality nursing care.

Assess

Getting the Information

Diagnosis

Identify the Problem

Plan

Determine actions to take

Implement

Take Action

Evaluate

Evaluate your outcomes and thinking

Subjective Data

Patient’s/family perception or feelings, not measurable/observable; symptoms.

Objective Data

What can be observed, perceived, and/or measure by another through the five senses; signs.

PQRSTU

P – palliate/provoke (What makes it better/worse?) Q – quality (Describe the pain – sharp, dull, pressure…) R – region/radiate (Where is the pain? Does it move?) S – severity (Can you rate it on a scale 0-10?) T – time (When did it start? Constant or intermittent?) U – understanding (What do you think is causing it?)

Cues

Pieces of information (data) perceived from the environment.

Inference

Interpretation/assigning meaning.

Primary Source of Data

Patient/client

Secondary Source of Data

All sources other than the patient, including family/support people, patient records, and health care professionals.

Identifying the Problem

Clinical judgment, follows analysis of data, and is the basis for interventions.

Planning

Prioritizing and goal setting, creating a written guideline for plan of care, determining direction of patient care.

Goals

Broadly stated and patient centered, rephrasing of priority problem.

Outcome Criteria

Indicate achievement of goal, observable, measurable, realistic, includes a target date, used in evaluation to determine if goal attainment.

Implementation

Implementing interventions – carrying out the plan – including doing, delegating, and recording.

Nursing Intervention

Any treatment, based on clinical judgment, and knowledge, to enhance client outcomes

Evaluation

Achievement of goals and outcomes, effectiveness of care, and modifications to plan/care.