NCM 1O1 PART 1

• The nursing process is a five-step problem-solving approach used by nurses to provide care to patients: assessment, diagnosis, planning, implementation, and evaluation

  
• The assessment phase involves gathering information about the patient's condition to identify problems and develop a care plan
• In the diagnosis phase, nurses identify the patient's problems based on the information gathered during assessment
• The planning phase involves setting goals for the patient's care and identifying nursing actions to achieve those goals
• During the implementation phase, nurses carry out the planned nursing actions
• In the evaluation phase, nurses determine if the patient's goals have been met based on the information gathered during implementation
• The nursing process is cyclical, with nurses returning to the assessment phase after the evaluation phase to monitor progress and make necessary changes to the care plan
• Assessment involves collecting, organizing, validating, and documenting client data to establish a database about the client’s response to health concerns or illnesses

  
• Diagnosis includes interpreting and analyzing data to identify client’s strengths and health problems that can be prevented or resolved by nursing interventions
• Planning involves setting priorities, goals, selecting interventions, and formulating a care plan in collaboration with the client
• Implementation includes carrying out planned nursing interventions, reassessing the client, and documenting care and client response
• Evaluation measures the degree to which goals have been achieved, identifies factors influencing goal achievement, and determines whether to continue, modify, or terminate the care plan
• In the diagnosis phase, nurses identify the patient's problems based on the information gathered in the assessment phase
• The planning phase in the nursing process involves setting goals for the patient's care and identifying nursing actions to achieve those goals
• The evaluation phase determines if the patient's goals have been met, based on the information gathered in the implementation phase
• The nursing process is an ongoing cycle, where after the evaluation phase, the nurse returns to the assessment phase to begin the process again
• Types of assessments in nursing include initial assessment, problem-focused assessment, emergency assessment, and time-lapsed assessment
• Data collection in nursing involves gathering information about a client's health status, including subjective data (symptoms) and objective data (signs)
• Sources of data in nursing include the client, support people, client records, health care professionals, and literature
• Data collection methods in nursing include observing, interviewing, and examining
• Observing in nursing involves gathering data using the senses, focusing on the patient/client and the environment
• Interviewing in nursing is a planned communication method, with approaches like highly structured or directive interviews, and open-ended questions to gather information
• Planning the interview in nursing involves considerations like time, place, seating arrangement, distance, language, and setting
• Stages of an interview in nursing include establishing rapport, opening, body (where the client communicates responses), and closing
• Physical examination in nursing involves techniques like inspection, auscultation, palpation, and percussion to detect health problems systematically
• Organizing data in health assessment includes using nursing health history, nursing assessment, or database forms
• Conceptual models or frameworks for assessment include Gordon’s Functional Health Patterns, Orem’s Self-Care Model, Roy’s Adaptation Model, and Wellness Models
• Factors and attitudes that influence levels of wellness are included in wellness models
• Non-nursing models like the Body Systems Model, Maslow’s Hierarchy of Needs, and Developmental Theories are also used in health assessment
• Validation of data involves "double-checking" to confirm completeness, accuracy, and agreement between subjective and objective data
• Cues in data are subjective or objective observations directly made by the nurse, while inferences are the nurse's interpretations based on cues
• Nurses should avoid jumping to conclusions and focus on differentiating between cues and inferences in data validation
• Documentation guidelines include recording date and time for each entry, ensuring legibility, using accepted terminology, correct spelling, and maintaining accuracy
• Accurate documentation in nursing should be factual, avoiding restating subjective data and refraining from judgements or conclusions
• Documentation should be done as soon as possible after an assessment or intervention, ensuring legibility and using dark ink or permanent pen
• Accurate notations in documentation consist of facts or observations, avoiding general words and writing on every line without leaving blank spaces
• Events should be documented in the order they occur, recording only information relevant to the client's health problems and care
• Complete documentation in nursing includes all assessments, interventions, client problems, comments, responses, progress, and communication with the healthcare team
• Documentation should be brief yet complete, omitting the client's name and using periods to end each thought
• Confidentiality and security of computer records in nursing require personal passwords, not leaving terminals unattended, and following facility policies for correcting entry errors