6339590
Description
Mind Map by Gwen Paparone, updated more than 1 year ago
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Created by Gwen Paparone
over 7 years ago
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The Nursing Process
- 1. Assessment = Verification of data Compare Subjective and objective Data factors altering accuracy, double check equipment
- A. Data Cllection
- Health Assessment= Health Hx, Database
- Physiologic Assessment= Physical Exam
- Health Assessment= Health Hx, Database
- B. Verification of Data
- Compare present report with Hx and PE
- Compare present report with Hx and PE
- C. Clustering of Data
- Organize Data into relevent diagnostic reasonings
- Organize Data into relevent diagnostic reasonings
- D. Documentation of Data
- Documentation of findings
- Use of any tools
- Be descriptive and concise with no interpretive statements
- Documentation of findings
- A. Data Cllection
- 2. Nursing Diagnosis _Use the North American Nursing Diagnosis Association List (Nanda)
- Nursing Dx= Based on Patients responses to actual or potential health problems or processes
- A. Analysis of Clustered Data and Pattern recognition
- B. Reasonable Conclusion identifying PT problems
- Compare o "normal" standards
- Compare o "normal" standards
- C. Write the Diagnostic statement using the formula (PES)
- Problem/ Label
- NANDA STATEMENT Within Nursing Scope of Practice,
- NANDA STATEMENT Within Nursing Scope of Practice,
- Etiology
- Related to....
- Related to....
- Signs and Symptoms
- As Evidenced By....
- As Evidenced By....
- Problem/ Label
- D. Types of Nursing Dx
- Actual - Existing at Present (PES)
- Constipation related to poor diet and lack of knowledge (diet and regular habits) as evidenced by reports of no BM for 5 days, firm & distended abdomen, and c/o abdominal discomfort and feeling of fullness.
- Constipation related to poor diet and lack of knowledge (diet and regular habits) as evidenced by reports of no BM for 5 days, firm & distended abdomen, and c/o abdominal discomfort and feeling of fullness.
- Risk- Potential Problems which may occur (PE)
- High risk for ineffective airway clearance related to ineffective cough.
- High risk for ineffective airway clearance related to ineffective cough.
- Possible- Suspicion of a problem without enough relevant data to back it up (PE)
- Possible fluid volume deficit related to inadequate intake and high alcohol consumption.
- Possible fluid volume deficit related to inadequate intake and high alcohol consumption.
- Wellness- When PT exhibits a health response, strenght or desire to improve upon something (Transition of one level of wellness to another level of wellness (1Part)
- Fluid balance, readiness for enhanced.
- Fluid balance, readiness for enhanced.
- Syndrome- Dx label contains etiology, Actual or high risk may reflect a cluster of nursing dx (P)
- Post trauma syndrome Impaired environmental syndrome Rape trauma syndrome Disuse syndrome Relocation stress syndrome
- Post trauma syndrome Impaired environmental syndrome Rape trauma syndrome Disuse syndrome Relocation stress syndrome
- Actual - Existing at Present (PES)
- A. Analysis of Clustered Data and Pattern recognition
- Medical Diagnosis = Based on an illness (Done by Physician)
- Nursing Dx= Based on Patients responses to actual or potential health problems or processes
- 3. Planning
- A. Prioritize
- 1. ABC's
- 2. Ask The Client
- 3. Analyze Relationship between Problems
- 4. Actual vs Risk
- 5. May use Maslow's Pyramid
- 1. ABC's
- B. Establishment of Goals/ Outcomes
- Cognitive Behaviors
- Affective /feeling
- Psychomotor/doing
- Outcomes must be SMART (Action Verbs) May use NOC
- Specific to PT
- Measurable/ Observable
- Attainable/ Realistic
- Time limited
- Specific to PT
- Cognitive Behaviors
- C. Develop Specific Nursing Interventions (NIC)
- Based on Science
- Individualized to client
- Address etiology of the nurisng Dx
- The Care Plan
- Must be Written
- Ensures Continuity of care
- Must be Written
- Based on Science
- A. Prioritize
- 4. Implementation
- 5. Evaluation
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