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The nursing process
A series of planned steps and actions directed toward meeting the needs and solving the problem of the clients and thier families
Characteristics of the nursing process
- goal oriented
- Purposeful, goal directed thinking that aims to make judgements based on facts.
- Requires a commitiment to seek the best way based on the most current research and practical findings.
- Involves processing information from more than one source to make a decision.
Critical thinking includes
- Inductive reasoning
- Deductive reasoning
Use specific data (signs and Symptoms) to identify a general data (dx)
Use general data (dx) to identify a specific data (signs and sx)
Four types of skills needed in the nursing process
- Critical thinking/cognitive/Intellectual
- Emotional intelligence
- the ability to accurately perseive, express, understand, and manage both one's own emotions and the emotions of others.
- the ability to manage emotions and handle stress are important predictors of career succes.
components of the NP
Framework for accountability for all
- Cl- improves quality of care
- Nurse- Knows that professional standards of care are being met, legally and ethically sound.
- Both- Time & resourses are used efficiently for the benefit of both nurse and cl.
- the systematic and continuous collection, validation, and communication of the client
- remaining steps depend on complete, accurate, factual, and relevent data
purpose of assessment
to form a database and obtain a baseline
types of data
- Objective-What you can observe, you can see, touch, hear, smell and taste.
- Subjective- stated data. Based o opinion and can not be varified
- Constant- data that does not change
- Variable- data that changes
Sources of data
- Primary- from the client, verbal and nonverbal
- Secondary- from others, family, nurses, records
- Tertiary- from text books, articles, reseach
Methods of collecting data
an organized series of questions for obtaning specific information about the cl.
Health history includes
- Basic Needs
- Life span
- Cultural diversity
Acutal or potential health problem that can be prevented or resolved by independant nursing intevention
summary of nursing assesment
- collect data
- validate/verify data
- organize data
- identify patterns
- report and record data
- designing a plan of care for the client that will result in solving or preventing client health problems
- Must include (who will do what by when)
know, learn, understand, feel, want
Components of planning
- Setting priorities
- Establishing cl goals and outcome goals
- Planning nursing strategies/implmentations/orders/interventions
- diagram of your conceptualization of nursing care to show connections and interrelationships.
- Mind mapping
5 main reason for writing a nursing care plan
- 1. Individualized care
- 2. Continuity of care
- 3. Direction about what needs to be documented
- 4. Guide for assigning staff and tasks
- 5. Documentation for third party reimbursement
- 6. Provides written proof for accountibility
consider availibility of clients needs, teaching needs, home environment
where the care plan and medical/ collaborative orders are carried out
Types of nursing actions
nurse is licensed to initiate these actions based on thier knowledge, education, and skills
Nurse carries out physicians's orders
performed jointly by nurse and other members of the health care team
written procedures to be followed in a partucular situation, may include both medical and nursing orders
allows the nurse to initiate actions that ordinarily require the ordor or supervision of an MD
- A. Reassessing trhe cl
- B. Determining the need for nursing care
- C. Implementing nursing strategies= carring out the plan
- D. Communicating the nursing orders, written and verbally
is the paln working? Measure and modify prn
Evidence based practice
a problem solving approch to practice that involves the conscientious use of the current best evidence in making decisions about cl care while also considering their values and preferences.