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Nursing Process
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an organized sequence of steps used to identify health problems and to manage client care
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Nursing Process
an organized sequence of steps used to identify health problems and to manage client care
Characteristics of the Nursing Process
1) Within the legal scope of nursing 2) based on unique knowledge 3) planned 4) client-centered 5) goal-directed 6)prioritized 7) dynamic
Steps in Nursing Process
1) Assessment 2) Diagnosis 3) Planning 4) Implementation 5) Evaluation
Resources for Data
1) Client 2) Client's Family 3) Medical records 4) other health care workers
Data Base Assessments
Provide vast information about a client at the time of admission
Focus Assessments
Which are ongoing, expand that database with additional information
Nursing Diagnosis
A health problem that nurses can treat independently
Collaborative Problem
A physiologic complication that requires the skills and interventions of both nurses and physicians
Nursing Diagnostic Statement in 3 parts
1) the problem 2) the etiology for the problem 3) signs and symptoms or evidence for the problem
Setting Priorities for Care
Helps to maximize efficiency in minimal time
Short-Term Goals
The nurse expects to accomplish in a few days to 1 week( usually when caring for clients in acute care settings
Long-Term Goals
Takes weeks to months to accomplish after discharge from health care agency.
Methods of Documentation
1) Writing the problems, goals, and nursing orders by hand 2) Individualizing a standardized or computer generated care plan 3)Following an agency's written standards for care or clinical pathways
Demonstrating Implementation of the plan of care by Nurses
Correlating the written plan with nursing documentation in the medical record
Evaluation of clients progression
1) Nurses orders are discontinued if the client has met the goal/ problem no longer exist. 2) Nurse revises the care plan if the client has made progress but the goal remains unmet/if there has been no progress in reaching a desired outcome
Concept Mapping
"Care Mapping"-A method of organizing information in a graphic or pictorial form. (The process involves drawing lines or arrows to link or correlate relationship within the map. This foundation provides a bridge for developing more complex skills like identifying nursing diagnoses, setting goals, and expected outcomes, implementing nursing interventions, and evaluating the results of care.)
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