Nursing Process Overview (Potter) Flashcards

Study Notes

Essential skill in the nursing process for organized and effective patient care.

Systematic method utilizing critical thinking to develop individualized care plans.
Involves gathering patient data, assessing needs, setting goals, and communicating with healthcare teams.

Assessment: Collection of patient data through observation, interviews, and physical exams.
Diagnosis: Analyzing and clustering patient data using standardized language for clarity among healthcare providers.
Planning: Prioritizing nursing diagnoses, identifying realistic, measurable, patient-focused goals, and specifying outcomes.
Implementation: Execution of specific nursing interventions to help patients achieve set goals.
Evaluation: Determining if patient goals are met and assessing intervention effectiveness, leading to adjustments in care plans.

A pregnant patient hospitalized due to chest pain and shortness of breath experiences consistent high blood pressure, leading to ongoing assessment and a medical diagnosis of blood clots.
Nursing diagnoses for the patient include comfort, gas exchange, and dietary needs, forming the basis for a tailored care plan including heparin therapy and dietary modifications.
Implementation involves regular patient education on self-injection of heparin and dietary choices to support medication effectiveness.
Ongoing evaluation at 30 weeks gestation confirms readiness for discharge, with continuous monitoring of heparin levels and lifestyle habits.

Nurse Lydia Hall (1955): Introduced the term "nursing process," illustrating nursing through three interlocking circles: care, core, and cure.
Dorothy E. Johnson (1959): Advocated for patient-centered care, emphasizing mental and physical balance by reducing stress and supporting adaptive processes.
Ida Jean Orlando (1961): Promoted the use of interpersonal relationships to meet patients' needs as defined by them, incorporating the patient into the health team dynamic.