Nursing Process Unit 1 Flashcards

Study Notes

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.

Description

Explore the fundamental concepts of the nursing process with these flashcards focusing on the first unit. Understand the crucial step of nursing assessment as it pertains to identifying patient needs and preferences. Perfect for nursing students looking to strengthen their knowledge.