nursing process chapter 4
nursing process
a decision making framework used by nurses to determine (identify) the needs of their paitents
an identified problem or risk of developing a problem
need
critical thinking
enables you to grasp the meaning of multiple clues and to find quick answers when facing difficult problems
aka important nursing strategy for problem-solving
ADPIE
(Steps of nursing process)
assessment, diagnosis, planning, implantation, evaluation
assessment
collect subjective and objective data
subjective data
information that is known only to the parent and family members
objective data
information you gather through observation with you senses
vision, touch, hearing, smell (olfaction)
example of objective data
large amount dark brown formed stool
75 ml dark amber urine
BP- 146/92
diagnosis
analyze the data collected through the assessment
the nursing diagnosis is related to the needs or problems a patient is experiencing or the risk of developing a problem
planning
a realistic time frame is selected for the problem to be resolved
implemention
the process of preforming the nursing interventions to resolve the problem
evaluation
the nurse reflects on the interventions performed and decides weather the patient is now closer to achieving the goals and outcomes set in the planning step
ANA (American nurses association)
all steps of the nursing process- from assessments through evaluation- responsibility of the RN
assessment
interviewing
develop a good rapport starting with your first interaction with the patient
primary data
patient provides the information
secondary data
obtain information from family members, friends, and the patients chart
5 techniques to collect objective data
inspection
the visual examination of the patients body
palpation
touching or feeling the body for pulses, temperature, moisture, abnormal lumps, vibrations
auscultation
listening with a stethoscope
percussion
a method of tapping body parts with fingers, hands, or small instruments as part of a physical examination
olfaction
sense of smell to detect odors
stethoscope
a sound transmitting device
defining characteristics
signs and symptoms exhibited by the patient
writing the nursing diagnosis
first- the problem
next- what is the problem related to
followed by- how is it evidenced by the patient
maslows hierarchy of needs
physiological needs
food, air, water, elimination, rest, and physical activity
safety and security
protection, emotional and physical safety, stability, and shelter
safe environment
love and beloning
giving and receiving affection, meaningful relationships, belonging to a group
develop a good rapport, support groups
self esteem
pride, sense of accomplishment, recognition by others
self actualization
personal growth, reaching potential
short term goal
achieve by discharge
long term goal
not expected by time of discharge
direct patient care
when nurse interacts directly with patient
indirect patient care
when the nurse provides assistance in a setting other than with the patient
(documenting, care conferences, receiving new orders)
evaluation
STOP AND REFLECT
look at nursing diagnosis and desired outcomes to determine if the nursing interventions brought about the anticipated outcome
types of nursing care plans
independent
no order required
dependent
order required
standard precautions
prevent infections
preforming intervention
implementation
nursing proces goal
patient centered
ABC'S
airway-breathing-circulation
what step in the nursing process would you preform a nursing intervention?
intervention stage