Questions and Answers
What is nursing assessment?
An identification by a nurse of the needs, preferences, and abilities of a patient.
What does nursing diagnosis refer to?
A statement of a health problem or potential problem that a nurse can treat.
What is the purpose of planning in nursing?
To design a strategy to achieve the goals of care for an individual patient.
What does implementation in nursing entail?
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What is the goal of evaluating in nursing?
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What are the purposes of the steps of the nursing process? (Select all that apply)
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What is a holistic assessment?
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What is the primary data source?
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What are secondary data?
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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.
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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.
