NCM 103 Fundamentals of Nursing Practice
Chapter 2: Nursing Process
4.1 Define the following terms
Nursing process - organized sequence of problem solving steps used to identify and manage
the health problems of clients; orderly, systematic method of providing care to clients
4.3 Identify the major characteristics of the nursing process
- Based on knowledge-requiring critical thinking
- Planned, organized, and systematic
- Client-centered
- Prioritized
- Continuity of care
- Individualized care
- Increased client participation
4.4 Discuss the phases of the nursing process
Assessment
- Gathering and analysis of information about a patient’s health status
Types of data
Objective data - overt; observable and measurable facts
Subjective data - covert; information that only the client feels and describe
Sources of data
Primary sources - client
Secondary sources - client’s family, reports, test results, current and past medical records,
discussion with other healthcare workers
Communication skills for effective communication
- Courtesy
- Comfort
- Connection
- Confirmation
If pain,
Character - describe the sign or symptom (feeling, appearance)
Onset - when did it begin?
Location - where is it? does it radiate? does it occur anywhere else?
Duration - how long does it last? does it reoccur?
Severity - how bad is it? how much does it bother you?
Pattern - what makes it better or worse?
Associated factors - what other symptoms occur with it?
Nursing Diagnosis
- Health issue that can be prevented, reduced, resolved, or enhanced through independent
nursing measures
- Not a medical diagnosis
Example:
Acute pain - nursing diagnosis
Chapter 2: Nursing Process
4.1 Define the following terms
Nursing process - organized sequence of problem solving steps used to identify and manage
the health problems of clients; orderly, systematic method of providing care to clients
4.3 Identify the major characteristics of the nursing process
- Based on knowledge-requiring critical thinking
- Planned, organized, and systematic
- Client-centered
- Prioritized
- Continuity of care
- Individualized care
- Increased client participation
4.4 Discuss the phases of the nursing process
Assessment
- Gathering and analysis of information about a patient’s health status
Types of data
Objective data - overt; observable and measurable facts
Subjective data - covert; information that only the client feels and describe
Sources of data
Primary sources - client
Secondary sources - client’s family, reports, test results, current and past medical records,
discussion with other healthcare workers
Communication skills for effective communication
- Courtesy
- Comfort
- Connection
- Confirmation
If pain,
Character - describe the sign or symptom (feeling, appearance)
Onset - when did it begin?
Location - where is it? does it radiate? does it occur anywhere else?
Duration - how long does it last? does it reoccur?
Severity - how bad is it? how much does it bother you?
Pattern - what makes it better or worse?
Associated factors - what other symptoms occur with it?
Nursing Diagnosis
- Health issue that can be prevented, reduced, resolved, or enhanced through independent
nursing measures
- Not a medical diagnosis
Example:
Acute pain - nursing diagnosis
