CU 1

• Nursing is both A SCIENCE and AN ART that is concerned with the individual’s Physical, Psychological, Sociological, Cultural, and Spiritual
• Health Assessment is the first step of the Nursing Process
• NURSING PROCESS IS A SYSTEMATIC PROBLEM-SOLVING APPROACH
• ✓ G - oal oriented ✓ O - rganized ✓ S - ystematic ✓ H - umanistic care
• 5 steps of the Nursing Process (ADPIE)ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
• ASSESSMENT is the most important step and it identifies your patient’s strengths and limitations and is performed not just once, but continuouslythroughout the nursing process
• DIAGNOSIS is the clinical judgment concerning a human response to health conditions/life processes, or vulnerability for that response by an individual, family, or community that the nurse is licensed andcompetent to treat
• An actual nursing diagnosis identifies an occurring health problem for your patient.
• A potential nursing diagnosis identifies a high-risk health problem that most likely will occur unless preventive measures are taken
• A possible nursing diagnosis is one that needs further data to support it
• Problem – focused ND - Problem + Etiology + Signs and Symptoms
• Risk ND - Problem + Etiology
• Health Promotion ND - Problem
• Syndrome ND - Specific clusters of nursing diagnoses that occur together and have similar nursing interventions to resolve the situation
• Defining Characteristics (Signs and Symptoms)- Observable assessment cues such as patient behavior, physical signs
• Related Factor (Etiology) - Etiological cause or causative factor for diagnosis
• PLANNING Involves setting goals and outcomes and Individualized plan of care for your patient is ready once diagnosis has been prioritized
• Priority Setting - Ordering of nursing diagnoses or patient problems using notions of urgency and importance to establish a preferential order for nursing interventions
• Goals - Broad statement that describes a desired change in a patient’s condition, perceptions or behavior
• Long Term Goals - objective behavior or response that you expect a patient to achieve over a longer period, usually over several days, weeks or months
• Short Term Goals - objective behavior or response that you expect the patient to achieve in short time usually few hours or less than a week
• Planning should be Specific, Measurable, Attainable, Realistic, and Time-bound
• INTERVENTION is defined as any treatment based on clinical judgment and knowledge that a nurse performs toenhance patient outcomes
• INTERVENTION, also called IMPLEMENTATION, Involves carrying out your plan to achieve goals and outcomes.
• Direct Care - Interventions are treatments performed through interaction with patient
• Indirect Care - Interventions are treatments performed away from a patient but on behalf of the patient or group of patient
• Independent - Action that the nurse initiates without supervision or direction from others
• Dependent - Actions that require an order from a health care provider
• Collaborative - Therapies that require the combined knowledge, skills, and expertise of multiple health care providers.
• EVALUATION - Final step of the nursing process
• EVALUATION - Crucial to determine if the patient’s condition improved or worsen after application of the first four steps of nursing process
• Initial Comprehensive Assessment - Involves collection of subjective data about the client’s perception of his or her health of all bodyparts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination.
• Ongoing or Partial Assessment - this consists of a mini-overview of the client’s body systems and holistic health patterns as a follow-up on health status.
• Focused or Problem-Oriented Assessment - It is performed when a comprehensive database exists for a client who comes to thehealth care agency with a specific health concern.
• Emergency Assessment - a very rapid assessment performed in life-threatening situations.
• acute care nurse - performs a focused assessment and then incorporatesassessment findings with a multidisciplinary team to develop a comprehensive plan of care.
• Critical care outreach nurses - need enhanced assessment skills to safely assess critically ill clients who are outside the structured intensive care environment.
• Ambulatory care nurses - assess and screen clients to determine the need for physician referrals.
• Home health nurses - make independent nursing diagnoses and referrals for collaborative problems as needed.
• Public health nurses - assess the needs of communities, school nurses monitor the growth and health of children, and hospice nurses assess the needs of the terminally ill clients and their families.