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Nursing
An art and a science that deals with human needs and challenges
Nursing Process
Involves critical thinking and a problem-solving approach that utilizes clinical judgement
to identify a nursing diagnosis of clients actual/potential problems, which assists with
planning an out-come focused nursing care plan
5 Nursing Process Steps
Assessment, Nursing diagnosis, Planning, Implementation, Evaluation (ADPIE)
Assessment
Gathering a comprehensive health history and other relevant data to identify the health
status of a client (Full Nursing, Head to toe, Focus)
Collecting and Recording data helps provide information required to...?
Predict, prevent and manage health problems.
Promote health and wellness
Diagnosis
Problem identification arises from the collection of assessment data and client interview.
NURSING Diagnosis
identifies an actual or potential problem that nurses can implement interventions and
monitor.
MEDICAL Diagnosis
the identification of a disease or condition by a doctor
What types of problems can we identify as a nurse?
Risk for injury
Knowledge Deficits
Self-care Deficits
Managing Pain
Problems that impede ability to be independent and live healthy lifestyle
How to write a nursing diagnosis
Problem (deficit, impairment, lack of), related factors (causes), evidence (supporting
proof) - (PRE)
SMART goals
Specific, Measurable, Achievable, Realistic, Time limited
Nurses initiated interventions need to be based upon...?
Evidence-based research
Evidence-informed practice...?
Ensures accurate, timely and appropriate clinical decisions are implemented
Implementation
- Established plan is activated
- Perform the intervention and assess the responses
- Data collection and prioritization of actions continues
- make immediate changes as needed
- Assessment is ongoing and documented