What is the nursing process? Answer - 1. assessment
2. diagnosis
3. planning
4. implementation
5. evaluation
Assessment Answer - this is the data-gathering stage, where you obtain
information from many sources. purpose is to gather data which is used to
draw conclusions about the patient's health status
Diagnosis Answer - - after analyzing the assessment data, synthesizing and
clustering information, and hypothesizing about the patient's health status, you
identify the patient's health needs and state this in the form of a problem
- nursing diagnosis's reflect the patient's response to actual or potential health
problems and are different from medical diagnoses
Planning (outcomes and interventions) Answer - this step can be divided into 2
phases
- working with the patient to decide upon goals for your care. these are the
patient outcomes you want to achieve through your nursing activities.
- you develop a list of individualized interventions that will assist the patient in
meeting the stated goals. the best interventions are evidenced-based
(supported by research)
,Implementation Answer - action phase - you implement or delegate the
interventions that you planned in step 3. in this phase, you msust document
your actions and the patients response to them
Evaluation Answer - determine whether the desired outcomes have been
achieved and also whether your outcomes have successfully treated or
prevented the patients health problems. if the outcome was not achieved, you
need to determined "why" and modify the plan of care (for example - add a
new intervention)
characteristics of the nursing process Answer - systematic, dynamic,
interpersonal, outcome oriented, universally applicable
systemic Answer - part of an ordered sequence of activities
dynamic Answer - great interaction and overlapping among the 5 steps
interpersonal Answer - human being is always at the heart of nursing
outcome oriented Answer - nurses and patients work together to identify
outcomes
universally applicable Answer - a framework for all nursing activities
What are the sources of data collection? Answer - subjective and objective
data
, subjective data Answer - - what the patient (or family member, neighbor, etc.)
says
- pertinent diagnostic indicators from verbal reports of individual or family
- record quotes when applicable
- check for consistency with objective data
- resolve in congruencies or inconsistencies
objective data Answer - - what the health professional observes
- lab data, vital signs, test results
- medical record
- pertinent diagnostic indicators from direct observation and examination of
individual and family, observations of context or milieu, and observational
reports of other care providers
types of health assessment Answer - 1. complete - initial, comprehensive
2. episodic - problem oriented
3. interval or follow up - changes from baseline
4. emergency - ABC's
communication goals Answer - - discover information that leads to the nursing
diagnosis and plan of care
- provide the patient with information regarding the diagnosis
- negotiate with the patient regarding healthcare management
- counsel about disease prevention
non-directive interviewing Answer - use to build rapport, promote
communication or help the patient express feelings
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