The Nursing Process

Gwen Paparone
Mind Map by Gwen Paparone, updated more than 1 year ago
Gwen Paparone
Created by Gwen Paparone about 5 years ago
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Description

NCLEX Nursing Mind Map on Untitled, created by Gwen Paparone on 14/09/2016.

Resource summary

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