The Nursing Process PDF

The Nursing Process\ A. Assessment\ a. Data collection\ Primary source: from the patient\ Secondary source: from the family, other institution, chart b\. Types of data\ Subjective: what the patient says, describes; symptoms\ Objective: What the caregiver observes, sees, feels, hears; signs c\. Cue...

The Nursing Process\ A. Assessment\ a. Data collection\ Primary source: from the patient\ Secondary source: from the family, other institution, chart b\. Types of data\ Subjective: what the patient says, describes; symptoms\ Objective: What the caregiver observes, sees, feels, hears; signs c\. Cues and inferences\ Cue: information that is collected\ Inference: judgement B. Diagnosis\ a. Cannot use medical terms\ Correct: altered breathing pattern related to pulmonary inflammatory\ process as evidenced by respiratory rate of 26\ Incorrect: Altered breathing pattern related to Pneumonia as evidenced\ by respiratory rate of 26 b\. PES\ Problem: difficulty breathing\ Etiology: Inflammatory process in the lungs with sputum production (or a\ more detailed scientific explanation)\ Signs and symptoms: RR: 26, productive cough of green sputum, dyspnea C. Planning\ a. Goals/patient outcomes b\. Must be measurable with time frame\ Patient will sit in the chair for 30 minutes three times a day c\. Consider Maslow's hierarchy and Erikson's developmental stages when\ planning goals d\. Must be patient centered e\. Short term and long term goals can be considered D. Implementation\ a. Actions by the nurse\ Assist patient to chair twice on day shift b\. Actions delegated by the nurse\ UAP will record urine output q6hours c\. Teaching\ Instruct patient how to empty JP drain d\. Assessment can be an action\ Assess lung sounds q4h e\. Direct care interventions: performed through interactions with patients\ f. Indirect care interventions: performed on behalf of the patient (ie: calling\ the physician for an order change) g\. The nurse/UAP must have the cognitive, psychomotor and interpersonal\ skills to carry out the action. In addition, it must be within their scope of\ practice E. Evaluation a\. Did the action work? b\. Did the patient meet his/her goal? c\. Can revise care plan at any step of the Nursing Process F. Types of diagnoses\ a. Actual: a problem exists\ b. Risk: potential for a problem to occur\ c. Health promotion: prevention or methods to stay healthy Difference between admission, head to toe, and focused assessments\ Critical thinking: Know the characteristics of critical thinking\ Document all care provided as well as the patient outcome/reaction to the\ intervention