Focused interviewing
Jeremiah
Terms in this set (16)
Collection of data from multiple sources
Review of clinical record
Interview
Nursing Process: Assessment
Health history
Physical examination
Cultural and spiritual assessment
Determine patient readiness and involve patient(s) in health care process
Review planned interventions with interdisciplinary health care team members to
Nursing Process: Implementation
facilitate collaborative effort
Document care provided
Interpretation of data by identifying clusters of cues so as to make inferences
Nursing process: Diagnosis Compare clusters of cues with definitions and defining characteristics
Validation of inferences based on findings
Establish priorities based on meeting identified patient care goals
Develop outcomes and set time frames for meeting proposed outcomes
Nursing process: Planning
Interdisciplinary meetings
Document plan of care
Refer to established outcomes
Evaluate individual's condition and compare actual outcomes with expected outcomes
Summarize results of evaluation
Nursing process: Evaluation
Identify reasons for failure to achieve expected outcomes
Take corrective action to modify plan of care
Document evaluation in plan of care
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