NCM 103 FN MODULE 4F Nursing Process flashcards in code format

Nursing Process

Systematic patient-centered method of providing individualized nursing care using 5 phases

5 Phases of Nursing Process

Assessment

Purpose of Nursing Process

To identify patient needs and provide safe individualized care

Critical Thinking

Precise and accurate use of data to make safe clinical decisions and prioritize care

When Nurses Use Critical Thinking

Setting priorities

Characteristics of Nursing Process

Cyclical

Trial and Error

Trying different solutions until one works; not used in emergencies

Intuition

Decision-making based on experience and instinct

Modified Scientific Method

Evidence-based practice using research

Assessment

Collecting

Subjective Data

Patient-reported symptoms like pain or feelings

Objective Data

Measurable signs like BP

Primary Data Source

Information directly from the patient

Secondary Data Source

Family

Validation of Data

Checking accuracy of collected information

Initial Assessment

First complete assessment during admission

Emergency Assessment

Rapid assessment in life-threatening conditions

Problem-focused Assessment

Focused assessment on current health issue

Time-lapsed Assessment

Follow-up comparison of current and previous data

Documentation

Recording patient data for communication and legal purposes

Nursing Diagnosis

Clinical judgment about patient response to health conditions

NANDA

Standardized nursing diagnosis classification system

Medical Diagnosis

Physician-based disease identification

Actual Diagnosis

Problem currently present with signs and symptoms

Risk Diagnosis

Problem likely to occur but not yet present

Wellness Diagnosis

Desire to improve health status

Syndrome Diagnosis

Cluster of related nursing problems

Possible Diagnosis

Suspected problem needing more data

Components of Nursing Diagnosis

Problem

Etiology

Cause of the nursing problem (related to)

Planning

Setting goals and choosing nursing interventions

Types of Planning

Initial

Goals

Broad expected outcomes

Desired Outcomes

Specific measurable results

SMART Goals

Specific

Implementation

Carrying out nursing interventions

Independent Intervention

Nurse-initiated actions

Dependent Intervention

Doctor-ordered actions

Collaborative Intervention

Team-based care actions

Nursing Skills

Cognitive

Evaluation

Determining if goals were achieved

Evaluation Outcomes

Goal met

Post Evaluation Action

Continue

ADPIE

Assessment