Term
|
Definition
The nursing process is the way one thinks like a nurse.
Allows nurses to communicate professionally.
It has specialized nursing from the beginning (not trained monkeys).
It demonstrates accountability to patients.
It is a method of providing efficient and effective nursing care. |
|
|
Term
STEPS OF THE NURSING PROCESS
ADPIE |
|
Definition
Assessment:
Thinking about what information to collect.
Collecting information.
Thinking about the significance of that information.
Drawing conclusions about how the patient is responding to his health or illness condition. |
|
|
Term
|
Definition
Analyze data to identify strengths to use in the development of the plan of care.
Look for gaps in data.
Develop actual or at risk problems, probably cause and supporting data. |
|
|
Term
|
Definition
Develop a plan of action (with the patient and family) to reduce or eliminate problems and promote health.
Key activities include:
Setting priorities: What problems need immediate attention? What problems need to be on the plan of care?
Establishing goals: Exactly what do you and the patient expect to accomplish and in what time frame?
Determining nursing interventions: What interventions will help achieve the goals? How and when will the interventions be done? |
|
|
Term
|
Definition
Putting the plan into action.
This involves the following activities:
Assess the patient’s current status: Is the plan still appropriate? Are there any new problems? Has anything changed that requires an immediate change in the plan?
Performing the interventions that were prescribed during planning.
Continue to assess the patient: What were the initial responses to your actions: Did it make a difference? Do you need to change something?
NCP is circular |
|
|
Term
|
Definition
Have any new problems developed? Are there new care priorities requiring different goals? Have the goals that were set during planning been achieved? Could more have been achieved? Should new goals be set? What made the plan work? What could have been done to make things easier?
Have the goal been only partially achieved or perhaps not at all: Why weren’t the goals achieved? Were the goals realistic? Are these goals still important? Did other problems impede your progress? Were the interventions appropriate? What changes are you going to make? |
|
|
Term
ASSESSMENT
(diagnostic part of NCP) |
|
Definition
- Collection of client health data
- Date base includes: demographics, history of present illness (HPI), social/cultural history, family history, coping strategies, activities of daily living (ADL’s), mental/emotional status, review of body systems (ROS), physical exam (PE), lab/diagnostic tests
- Needs constant updating, ongoing throughout NP
- Sources of data collection include:
- Primary: the client (Data obtained through observation, interviewing, physical exam)
- Secondary: family, friends, lab/dx reports, other members of the health care team
- Observation
- Subjective: (symptoms, statements) – what the individual tells you he/she is feeling, hearing, seeing, thinking
- Objective: (signs, observations) – obtained by observing
|
|
|
Term
|
Definition
- Be aware of judgments made by the patient and yourself
- Using therapeutic communication helps to identify health care needs. (Do not ask, “Do you have problems with your bowels?” as an individual with UC/CD, D may be the norm. Instead ask, “What is your normal bowel pattern?” It is very difficult for beginning nursing students to talk and do an assessment at the same time.
- A screen health exam is just a basic exam, whereas a focus assessment concentrates on a particular body system or complaint.
|
|
|
