Nursing Process Unit 1 Flashcards

Nursing Process Overview

• The nursing process consists of five essential steps: assessment, diagnosis, planning, implementation, and evaluation.
• These steps enable organization of patient care, ensure comprehensive care, and facilitate evaluation of patient outcomes.

Nursing Assessment

• Involves identifying patient's needs, preferences, and abilities through interviews and observations.
• Assesses vital signs, skin conditions, motor/sensory functions, nutrition, sleep, activity, and consciousness.
• Provides a scientific foundation for developing a complete nursing care plan.

Nursing Diagnosis

• A statement identifying actual or potential health problems that nurses are qualified to address.
• Formulation involves data collection from multiple sources: patient interviews, family input, existing health records, observations, and consultations.
• Four key steps: data base establishment, analysis of responses, organization of data into a diagnostic statement, and confirmation of diagnosis accuracy.
• Each diagnosis includes a concise problem description, probable cause, and defining characteristics.

Planning

• A strategic phase to achieve established care goals for individual patients.
• Involves developing and modifying care plans, collaborating with other healthcare personnel, and documenting relevant information.

Implementation

• The active execution of care plans through deliberate actions aimed at achieving patient goals.

Evaluating

• Determines the extent to which care goals have been met and records the findings.
• The evaluation process includes assessing implementation success, patient compliance, and responses to therapies.
• Addresses the need for care adjustments and evaluates the impact on patients, families, and healthcare staff.

Holistic Assessment

• Emphasizes a comprehensive evaluation of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health.
• A holistic approach helps in gaining a better understanding of the patient's overall condition.

Data Collection in Nursing

• Data collection begins with the first encounter with a patient and can be classified as primary or secondary.
• Primary data are directly obtained from the patient.
• Secondary data are gathered from friends, family, healthcare professionals, and written sources, such as medical records and test results.