Nursing is an art of applying scientific principles in a humanitarian way to care of people
Health assessment is an essential nursing function which provides foundation for quality nursing care and intervention.
Nursing process serves as the organizational framework for the practice of nursing.
Diagnosis – It is the determination of the nature and extent of a disease.
Prognosis – It is the forecast of the course and duration of a disease.
Etiology – It is the science of the cause of a disease.
Signs – The presence of a disease that can been seen or elicited
Symptoms – Any evidence as to the nature and location of a diseases noted by the client.
Assessment is the first stage of the nursing process in which the nurse should carry out a complete and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter.
Assessment Process Is a systematic method by which nursing plans and provides care for patients.
Assessment Process involves a problem-solving approach that enables the nurse to identify patient problems and potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly, scientific manner.
Nursing Process ANA defines the nursing process as the “essential core of practice for the registered nurse to deliver holistic, patient-focused care“
Nursing Process 5 components assessment, diagnosis, planning, implementation, and evaluation.
NursingProcess series of steps that the nurse takes in planning and giving nursing care. It provides a logical framework on which the nursing care is based
Assessment a deliberate, systematic and logical collection of subjective and objective data that are helpful to identify and define problems of the client, before the nurse proceeds to plan the care.
Subjective data are the client’s feelings and statements about his or her health problems.
Objectivedata are observable, perceptible and measurable data during physical examination using techniques-measurable information such as vital signs, auscultation, visual appearance, lab values
Primary source is the client himself
Secondary source are the health sources include family members or significant others, health record, laboratory tests and diagnostic procedures, health team members and literature review.
Diagnosis is the clinical act of identifying the problems. involves a nurse making an educated judgment about a potential or actual health problem with a patient.
Diagnostic label is the name of the nursing diagnosis. It describes the essence of the problem using as few words as possible
Qualifiers are words used to give additional meaning to a nursing diagnosis.
Definition describes the characteristics of the human response under consideration.
Defining characteristics are major and minor clinical cues that validate the presence of an actual nursing diagnosis
Risk factors are identifiable intrinsic and extrinsic characteristics of the client.
Related factors: they describe the conditions, circumstances or etiologies that contribute to the problem.
Problem-focused diagnosis - also known as actual diagnosis. is a client problem that is present at the time of the nursing assessment. are based on the presence of associated signs and symptoms.
Problem-focused nursing diagnoses have three components: nursing diagnosis, related factors, and defining characteristics
Risk Nursing Diagnosis These are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene. no etiological factors
Health Promotion Diagnosis also known as wellness diagnosis. is a clinical judgment about motivation and desire to increase well-being. is concerned in the individual, family, or community transition from a specific level of wellness to a higher level of wellness.
Syndrome Diagnosis is a clinical judgment concerning with a cluster of problem or risk nursing diagnoses that are predicted to present because of a certain situation or event
Planning the nurse sets measurable and achievable short- and long-term goals for the patient.
All patient goals should follow the "SMART" framework: Specific, Measurable, Attainable, Relevant, and Time-Bound
Implementation This is the action phase of the nursing process. It is the actual initiation of the plan and documenting of nursing actions. involves both direct and indirect patient care
Independent ( Nurse initiated )- any action the nurse can initiate without direct supervision
Collaborative- nursing actions performed jointly with other health care team members
Evaluation last phase of the nursing process which include the judgment of the effectiveness of nursing care to meet client goals based on the client’s behavioral responses. determine the success/effectiveness of the whole nursing process and the decision either to continue, modify or repeat the process is depend on evaluation.
Nursing Care Plan provides direction on the type of nursing care the patient may need. to facilitate standardised, evidence-based and holistic care
Initial Comprehensive Assessment is usually the initial assessment it very thorough and includes detailed health history and physical examination and examine the client's overall health status