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NURSING PROCESS
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A SYSTEMATIC PROCESS THAT IS RATIONAL, CONTINUOUS, CYCLICAL AND DYNAMIC, GOAL-ORIENTED, CLIENT CENTERED AND INTERPERSONAL, COLLABORATIVE AND UNIVERSALLY APPLICABLE
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FIVE STEPS OF THE NURSING PROCESS
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ASSESSMENT, DIAGNOSIS OR ANALYSIS, PLAN, IMPLEMENT AND EVALUATE
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ASSESSMENT PURPOSE
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TO ESTABLISH A DATABASE ABOUT THE CLIENTS RESPONSE TO HEALTH CONCERNS OR ILLNESS AND THE ABILITY TO MANAGE HEALTH CARE NEEDS
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HOW TO ESTABLISH A DATABASE
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OBTAIN A NURSING HEALTH HISTORY CONDUCT A PHYSICAL ASSESSMENT REVIEW CLIENT RECORDS REVIEW NURSING LITERATURE CONSULT SUPPORT PERSONS
CONSULT HEALTH PROFESSIONALS
-UPDATE DATA AS NEEDED
-VALIDATE DATA
-COMMUNICATE/DOCUMENT DATA
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PURPOSE OF DIAGNOSING
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TO IDENTIFY CLIENT STRENGTH AND HEALTH PROBLEMS THAT CAN BE PREVENTED OR RESOLVED BY COLLABORATIVE AND INDEPENDENT NURSING INTERVENTIONS. TO DEVELOP A LIST OF NURSING DIAGNOSIS AND COLLABORATIVE PROBLEMS. INTERPRET AND ANALYZE DATA
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STEPS TO INTERPRET AND ANALYZE DATA FOR DIAGNOSING
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COMPARE DATA AGAINST STANDARDS
CLUSTER OR GROUP DATA (GENERATE TENTATIVE HYPOTHESIS)
IDENTIFY GAPS OR INCONSISTENCIES
DETERMINE CLIENTS STRENGTHS, RISKS, AND PROBLEMS
FORMULATE NURSING DIAGNOSIS AND COLLABORATIVE PROBLEM STATEMENTS
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PURPOSE OF PLANNING
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TO DEV ELOPE AN INDIVIDUALIZED CARE PLAN THAT SPECIFIES CLIENT GOALS/DESIRED OUTCOMES AND RELATED NURSING INTERVENTIONS
SET PRIORITIES AND GOAL/ OUTCOMES IN COLLABORATION WITH THE CLIENT
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STEPS OF PLANNING
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WRITE GOALS/ DESIRED OUTCOMES
SELECT NURSING STRATEGIES/ INTERVENTIONS
CONSULT OTHER HEALTH PROFESSIONALS
WRITE NURSING ORDERS AND NURSING CARE PLAN
COMMUNICATE CARE PLAN TO RELEVANT HEALTH CARE PROVIDERS
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PURPOSE OF IMPLEMENTING
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TO ASSIST THE CLIENT TO MEET DESIRED GOALS/OUTCOMES; PROMOTE WELLNESS; PREVENT ILLNESS AND DISEASE; RESTORE HEALTH; AND FACILITATE COPING WITH ALTERED FUNCTIONING
REASSESS THE CLIENT TO UPDATE DATABASE
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STEPS OF IMPLEMENTING
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DETERMINE NEED FOR NURSING ASSISTANCE
PERFORM OR DELEGATE PLANNED NURSING INTERVENTION
COMMUNICATE WHAT NURSING ACTIONS WERE IMPLEMENTED
DOCUMENT CARE AND CLIENT RESPONSE TO CARE
GIVE VERBAL REPORTS AS NECESSARY
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PURPOSE OF EVALUATING
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TO DETERMINE WHETHER TO CONTINUE, MODIFY, OR TERMINATE THE PLAN OF CARE
COLLABORATE WITH CLIENT AND COLLECT DATA RELATED TO DESIRED OUTCOMES
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STEPS TO EVALUATING
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JUDGE WHETHER GOALS/ OUTCOMES HAVE BEEN ACHIEVED
RELATE NURSING ACTIONS TO CLIENT OUTCOMES
MAKE DECISIONS ABOUT PROBLEM STATUS
REVIEW AND MODIFY THE CARE PLAN AS INDICATED OR TERMINATE NURSING CARE
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STANDARDS OF CARE
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AUTHORITATIVE STATEMENTS THAT DESCRIBE A COMMON OR ACCEPTABLE LEVEL OF CLIENT CARE OF PERFORMANCE. STANDARDS OF CARE DEFINE PROFESSIONAL PRACTICE.
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ASSESSMENT
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SYSTEMIC COLLECTION VERIFICATION, ORGANIZATION, INTERPRETATION AND DOCUMENTATION OF DATA TO ESTABLISH A DATABASE
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TYPES OF ASSESSMENT
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FOCUSED
ONGOING
COMPREHENSIVE
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TYPES OF DATA
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PRIMARY
SECONDARY
SUBJECTIVE
OBJECTIVE
HEALTH HISTORY
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DIAGNOSIS OR ANALYSIS
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ANALYSIS OR SYNTHESIS OF DATA TO IDENTIFY THE PT'S ACTUAL OR POTENTIAL NURSING DIAGNOSIS
DATA IS ANALYZED AND NURSING DX. IS IDENTIFIED
DIAGNOSTIC STATEMENTS ARE WRITTEN
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NURSING DIAGNOSIS
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FIRST ACTUAL NURSING DX. IS THE PROBLEM STATEMENT OR DIAGNOSING LABEL
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THREE CATEGORIES OF NURSING DIAGNOSIS
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ACTUAL
RISK
WELLNESS
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PRIORITIES ACCORDING TO MASLOW'S HIERARCHY OF NEEDS
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1. PHYSIOLOGICAL
2. SAFETY AND SECURITY
3. LOVE AND BELONGING
4. SELF ESTEEM
5. SELF ACTUALIZATION
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COMPONENTS OF NURSING DX.
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1. ACTUAL NURSING DX. OR PROBLEM STATEMENT
2. ETIOLOGY THAT IS R/T THE CAUSE OR CONTRIBUTOR
3. DEFINING CHARECTERISTICS OR S/S SUBJECTIVE DATA OR CLINICAL MANIFESTATION - DX. IS VALIDATED
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PLANNING OR OUTCOME IDENTIFICATION INCLUDES:
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1. GUIDELINES TO ESTABLISH A COURSE FOR NURSING ACTION TO RESOLVE NURSING DX
2. DEVELOPMENT OF A PLAN OF CARE
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PURPOSE OF PLANNING
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1. PRIORITIZE PROBLEMS OF DIAGNOSIS
2. ESTABLISH GOALS AND EXPECTED OUTCOMES
3. TO DEVELOP PLAN OF CARE THROUGH GOALS ACHIEVED FROM NURSING INTERVENTIONS
4. TO ESTABLISH OUTCOME CRITERIA USED TO EVALUATE IF GOALS ARE MET
5. TO DELEGATE NURSING ACTIVITIES TO APPROPRIATE HEALTH CARE TEAM MEMBERS
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THREE PHASES OF NURSING CARE
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1. INITIAL PLANNING
2. ONGOING PLANNING
3. DISCHARGE PLANNING
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INITIAL PLANNING
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DEVELOPMENT OF PRELIMINARY PLAN OF CARE
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ONGOING PLANNING
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CONTINUOUS UPDATING OF THE PLAN OF CARE
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DISCHARGE PLANNING
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PLANNING OF PT'S NEEDS AFTER DISCHARGE
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WHERE DOES OUTCOME IDENTIFICATION COME FROM
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GOALS AND EXPECTED OUTCOMES FOR EACH NURSING DIAGNOSIS
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GOALS
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BROAD STATEMENTS THAT DESCRIBE THE INTENDED OR DESIRED CHANGE IN THE CLIENTS CONDITION
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EXPECTED OUTCOMES
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IDENTIFIED AFTER GOALS ESTABLISHED
MORE SPECIFIC THAN GOALS
REALISTIC AND MEASURABLE
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WHEN CAN NURSING INTERVENTIONS BE FORMULATED
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AFTER GOALS AND EXPECTED OUTCOMES ARE ESTABLISHED
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TYPES OF NURSING INTERVENTIONS
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INDEPENDENT
INTERDEPENDENT
DEPENDENT
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INDEPENDENT NURSING INTERVENTION
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ACTIONS THAT NURSE INITIATES
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INTERDEPENDENT NURSING INTERVENTIONS
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ACTIONS THAT ARE IMPLEMENTED IN COLLABORATION WITH OTHER HEALTH CARE PROFESSIONALS
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DEPENDENT NURSING INTERVENTIONS
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ACTIONS THAT REQUIRE AND ORDER BY A PHYSICIAN OR ANOTHER HEALTH CARE PROFESSIONAL.
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NURSING CARE PLAN
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ORGANIZED FORMAL STATEMENTS OF STRATEGIES THAT WILL BE IMPLEMENTED AND IS WRITTEN IN A PLAN
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PROTOCOL
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A SERIES OF STANDING ORDERS OR PROCEDURES THAT SHOULD BE FOLLOWED UNDER CERTAIN CONDITIONS
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NURSING PRACTICE ACT
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A STATUTE THAT IS ENACTED BY THE LEGISLATURE OF A STATE AND OUTLINES THE SCOPE OF NURSING PRACTICE IN THAT STATE
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AMERICAN NURSES ASSOCIATION (ANA)
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HAS ESTABLISHED STANDARDS FOR NURSING PRACTICE AND EDUCATION TO IMPROVE THE QUALITY OF CARE
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STANDARDS OF PRACTICE
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MAY BE OUTLINED IN POLICY AND PROCEDURE MANUALS OF A FACILITY
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IMPLEMENTING OR INTERVENING
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INVOLVES THE EXECUTION OF THE NURSING CARE PLAN
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REQUIREMENTS FOR IMPLEMENTATION
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1. CONSTANT REASSESSMENT OF INTERVENTIONS TO SEE IF THEY ARE STILL NEEDED
2. ASSESSMENT OF CLIENT'S CONDITION BEFORE, AFTER, AND DURING Q INTERVENTION
3. DOCUMENT INTERVENTIONS AND RESPONSE
4. PROMOTE CONTINUITY OF CARE
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DELEGATION
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PROCESS OF TRANSFERRING SELECTED NURSING TASKS TO LICENSED PERSONNEL WHO ARE COMPETENT
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EVALUATION
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INVOLVES DETERMINING WHETHER THE CLIENT GOALS HAVE BEEN MET, PARTIALLY MET OR NOT MET
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VARIABLES AFFECTING OUTCOMES
REASONS GOALS AREN'T MET
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1. INITIAL ASSESSMENT INCOMPLETE
2. GOALS WEREN'T REALISTIC
3. TIME FRAME WAS INAPPROPRIATE
4. GOALS OR INTERVENTIONS WEREN'T APPROPRIATE
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WHO DEFINITION OF HEALTH
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A STATE OF COMPLETE PHYSICAL, MENTAL, AND SOCIAL WELL BEING, NOT MERELY THE ABSENCE DISEASE OR INFIRMITY
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HEALTH/WELLNESS CONTINUUM
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THE RELATIONSHIP THAT DEPICTS HEALTH AND ILLNESS AS EXTREME ELEMENTS AT THE OPPOSITE STATUS POINTS ON THE LINE
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HIGH LEVEL WELLNESS (PER HL DUNN)
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CONCEPT THAT IS RELATED TO FAMILY, COMMUNITY, ENVIRONMENT AND SOCIETY
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FAMILY WELLNESS ENHANCES __________
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INDIVIDUAL WELLNESS
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COMMUNITY WELLNESS ENHANCES _________
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FAMILY ENVIROMENT
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