Foundations: Nursing Process/Nursing Diagnoses – Flashcards
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Why is it important to identify a nursing process?
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clarify the scope of our practice identify what is unique to our practice facilitate dialogue in provision of interdisciplinary pt care
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In 1967 we developed a nursing process we have mostly stuck to. what are the 4 words to represent this process?
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assessment planning implementation evaluation
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We don't heal people so what do we do?...
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create an environment that promotes healing
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What changed the pay system in the nursing process?
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outcome identification (a distinct step in the nursing process)
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What are the 6 steps that define the nursing process (What we will go through with each patient with our preceptor in clinical)
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Assessment Nursing Diagnosis Outcome Identification Planning Implementation Evaluation
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What is Assessment?
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A collection of subjective and objective data ( this will continously be revised as pt conditions change)
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What is the primary source to gathering your assesment?
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The pt
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What is the secondary source to gather your assesment?
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family health record lit review S/O
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Why is the initial assessment so important?
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it becomes the reference point for all further nursing assessments and is crucial in determining plan of care. (sets the baseline)
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What is an outcome identification?
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Formulating and documenting a measurable, realistic, client-focused goal.
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What does a nurse do in regards to planning?
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work with clients to identify goals and interventions strateges that will reduce identified problems
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What is the evaluation step in the nursing plan of care?
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it identifies whether or not the identified outcome was achieved or not.
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What is a nursing diagnosis?
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A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. ( Diagnosis= indentifies the plan of care)
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What are the 4 types of nursing diagnosis?
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Actual Nursing Diagnosis (the one we mostly focused on in the lecture) Risk Nursing Diagnosis Wellness Nursing diagnosis Possible Nursing diagnosis
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What are the 3 parts to the actual nursing diagnosis?
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Diagnosis label (NANDA approved) related factors defining characters
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What kind of diagnosis are acceptable in our scope of practice?
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Nursing diagnosis NOT a medical diagnosis
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What are the 2 parts to the Risk Nursing Diagnosis?
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NANDA approved label Risk factord (risk of infection related to surgery and immunosuppression)
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What are the 2 parts to the Risk Possible Nursing Diagnosis?
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Diagnostic label (NANDA approved) Related factors (Possible Self-Esteem Disturbance related to unknown etiology)
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What is a Wellness Diagnosis?
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NANDA Diagnostic label (Potential for enhanced parenting)
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What does AEB stand for?
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as evidenced by
