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Thursday, October 4, 2012

FON: Nursing Process




ASSESSMENT PHASE

-          Data Collection
-          Organize Data
-          Validate Data
-          Document Data
Subjective Data  also referred to as symptoms or covert data
Objective Data also referred to as signs or overt data, are detectable by an observer
Primary source is the client
Secondary source is family or anyone else that is not the client

Methods of Data Collection
Observing To observe is to gather data by using the sense.
Interviewing Is a planned communication or a conversation with purpose
Examining Is a systematic data-collection method that uses observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.

DIAGNOSIS PHASE
-          Analyze Data
-          Identify Health Problem
-          Formulate Diagnostic Statements

Diagnostic Statements
Problem (P): statement of the client’s response.
Etiology (E): factors contributing
Signs and Symptoms (S): defining characteristics manifested by the client

Types of Nursing Diagnosis

Actual diagnosis is a client problem that is present at the time of the nursing assessment.
Risk nursing diagnosis is a clinical judgment that a problem does not exist, but the presence of risk factors
Wellness diagnosis
Possible nursing diagnosis is one in which evidence about a health problem is incomplete or unclear.
Syndrome diagnosis is a diagnosis that is associated with a cluster of other diagnoses
.
PLANNING PHASE

-          Prioritize problems
-          Formulate goals
-          Select actions
-          Write nursing orders
Types of Planning

Initial planning, admission assessment.
Ongoing planning
Discharge planning:
M edications
E xercise
T reatment/therapy
H ygiene
O ut-patient follow up
D iet/nutrition
S exual activity/spirituality

INTERVENTION /
IMPLEMENTATION

-     Determining needs for assistance
-     Putting into action the plan
-     Supervising delegated care
-      Documenting nursing activities
Types of Intervention
         Independent
         Dependent
         Collaborative

Cognitive or Intellectual Skills Such as analyzing the problem, problem solving, critical thinking and making judgments regarding the patient's needs.
Interpersonal Skills
Which includes therapeutic communication, active listening, conveying knowledge and information, developing trust or rapport-building with the patient
Technical Skills Which includes knowledge and skills needed to properly and safely done the procedure

EVALUATION PHASE
Collecting data related to outcome
Comparing data
Drawing conclusion
Continuing, modifying or  terminating the nursing care plan
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