NURSING PROCESS (HAS)

• HEALTH ASSESSMENT - an essential nursing function that provides foundation for quality nursing care and interventions.
• HEALTH ASSESSMENT - the most important because it is a direct process, and it is the first step of the nursing process.
• HEALTH ASSESSMENT - identify and differentiate the normal to abnormal.
• NURSING PROCESS - a systematic organized method of planning providing quality and individualized nursing care.
• NURSING PROCESS - systematic problem solving approach.
• ASSESSMENT - the most important step, identifies the patient strength and limitations is performed not just once but continously.
• ASSESSMENT -

  • collecting
  • organizing
  • validating
  • documenting
• INITIAL COMPREHENSIVE ASSESSMENT - DATABASE, origin and nature of the problem and to use that information for the next assessment stage.
• PROBLEM ORIENTED ASSESSMENT - the problem is existent and fully exposed and treated in focused assessment phase.
• TIME LAPSED ASSESSMENT - conducted to evaluate how the patient reacts to the greed treatment plan and how their condition is evolving.
• EMERGENCY ASSESSMENT - performed during emergency or life threatened problems, evaluating patients airway, breathing and circulation.
• DIAGNOSIS - problem identification, client responses to actual and potential health problems or life process.
• MEDICAL DIAGNOSIS - DOCTOR, focuses on the disease process and pathology.
• NURSING DIAGNOSIS - nurses, focuses on human responses.
• ACTUAL NURSING DIAGNOSIS - existent problem, present at the time of nursing assessment.
• HEALTH PROMOTION DIAGNOSIS - CLIENT PREPAREDNESS, willingness to learn about the health maintenance.
• RISK NURSING DIAGNOSIS - a problem does not exist, and most likely to develop.
• SYNDROME NURSING DIAGNOSIS - cluster of different signs and symptoms.
• MAIN OBJECTIVES OF PLANNING -

  • establish priorities
  • develop smart goals
  • establish expected outcomes
  • identify interventions
  • document the care plan
• TYPES OF PLANNING

  • initial - upon admission
  • ongoing - during confinement
  • discharge - before going home
• INTERVENTION - also called "implementation" the doing phase and defined as any treatment based on clinical judgement and knowledge that a nurse performs to.
• INDEPENDENT INTERVENTIONS - nurse initiated, any actions that nurse can initiate or do without direct supervisions.
• DEPENDENT INTERVENTIONS - physician initiated, requiring doctors order.
• COLLABORATIVE INTERVENTIONS - nursing actions performed jointly eith other health care team members.
• EVALUATION - is a planned ongoing, purposeful activity in which the client progress towards achieving the goals or desired outcomes and the effectiveness of the nursing care plan.
• EVALUATION - an essential aspect of the nursing process because conclusion drawn from this step to determine whether nursing interventions should be terminated, continued or change.