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purpose of nursing process - SOLVED ANSWER-is to diagnose and treat human
responses to actual or potential health problems
nursing process - SOLVED ANSWER-consists of 5 phases:
assessment,
diagnosis,
planning,
implementation,
evaluation
ana scope and standards of practice - SOLVED ANSWER-Standard 1. Assessment
"The RN collects pertinent data and information relative to the healthcare consumer's
health or the situation."
Standard 2. Diagnosis
"The RN analyzes assessment data to determine actual or potential diagnoses,
problems, and issues."
Standard 3. Outcomes Identification
"The RN identifies expected outcomes for a plan individualized to the healthcare
consumer or the situation."
Standard 4. Planning
,"The RN develops a plan that prescribes strategies to attain expected, measurable
outcomes."
Standard 5. Implementation
"The RN implements the identified plan."
5A Coordination of Care
5B Health Teaching and Health Promotion
Standard 6. Evaluation
"The RN evaluates progress toward attainment of goals and outcomes."
assessment - SOLVED ANSWER-first step.
Collect data/ information
assessment process - SOLVED ANSWER-Begins: initial meeting between nurse &
client/family
Next step: obtain info about the clients current and past problems.
Analyze data: organize cluster behavior and make inference on S&O.
Verify data: validate data and inferences with client.
Types of info to collect from client for assessment - SOLVED ANSWER-History-
past records and tests,
other health care team members, family history.
, Physical exam-
observation,
current tests,
measurements
Assessment: data collection - SOLVED ANSWER-two types:
Subjective (states)
and Objective (observed)
Nursing Diagnosis - SOLVED ANSWER-a comprehensive biopsychosocial statement
that captures the essence of the clients health care needs/ problems.
Nursing Diagnosis cont. - SOLVED ANSWER--developed & prioritized based on the
clients most immediate needs in the current health care situation.
-describes the clients human responses to health issues & medical diagnoses.
Subjective (stated) - SOLVED ANSWER-clients perception of data & what client or
family says about the data.
Document: patient states, "..."
history
Objective (observed) - SOLVED ANSWER-data directly observed or verified through
physical exams or tests.
documents specific, measurable terms