The term NURSING PROCESS was first used/mentioned by Lydia Hall, a nursing theorist, in 1955 wherein she introduced

3 STEPs: observation, administration of care and validation.

Since then, nursing process continue to evolve: it used to be a 3-step process, then a 4-step process (APIE), then a 5-step (ADPIE), now a 6-step process (ADOPIE) ASSESSMENT, DIAGNOSIS, OUTCOME IDENTIFICATION, PLANNING, IMPLEMENTATION and EVALUATION. NURSING PROCESS is a systematic, organized method of planning, and providing quality and individualized nursing care. it is synonymous with the PROBLEM SOLVING APPROACH that directs the nurse and the client to determine the need for nursing care, to plan and implement the care and evaluate the result. It is a G O S H approach (goal-oriented, organized, systematic and humanistic care) for efficient and effective provision of nursing care.

Goal-oriented nurse make her objective based on clients health needs. Remember : Goals and plan of care should be base according to clients problems/needs NOT according to your own problem as the nurse. Organized/Systematic the nursing process is composed of 6 sequential and interrelated steps and these 6 phases follow a logical sequence. Humanistic care plan to care is developed and implemented taking into consideration the unique needs of the individual client. plan of care therefore is individualized (no 2 person has the same health needs even with same health condition/illness) in providing care, it involves respect of human dignity Efficient plan of case is relevant/related to the needs of the client thereby promoting client satisfaction and progress. Effective in planning care, utilized resources wisely (staff, time, money/cost)

Aside from GOSH, other characteristic of Nursing Process Cyclic and Dynamic in nature data from each phase provides the input into the next phase so that is becomes a sequence of events (cycle) that are constantly changing (dynamic) base on clients health status. Involves skill in Decision-making nurse makes important decisions related to client care, she choose the best action/steps to meet a desired goal or to solve a problem. She must make decisions whenever several choices or options are available. Uses Critical Thinking skills the nurse may encounter new ideas or less-than-routine or nonordinary situations where decisions must be made using critical thinking. Purpose of Nursing Process: 1. To identify a clients health status; his Actual/Present and potential/possible health problems or needs. 2. To establish a plan of care to meet identified needs. 3. To provide nursing interventions to meet those needs. 4. To provide an individualized, holistic, effective and efficient nursing care. Steps/Phases of the Nursing Process: 1. 2. 3. 4. 5. 6. Assessment Diagnosis Outcome Identification Planning Implementation Evaluation

DPIE is the step by step clinical layout of the nursing process, it consists of? Assessment, Diagnosis, Planning Interventions, Implementation, and Evaluating Outcomes.

What is the purpose of a nursing assessment? To collect data relevant to delivering nursing care.

How is assessment relevant to the rest of the nursing process? It is the foundation for the remainder of the process, it provides data needed to identify actual or potential health problems.

What are the four types of data sources? primary, secondary, subjective, objective.

Define subjective data.

It is information gathered directly from the pt.

Define objective data. It is information gathered through your 5 senses.

Define primary data. Comes directly from the source.

Describe secondary information. Data that comes form outside the source.

The comprehensive assessment is composed of 3 points, they are? Observation, Physical Exam, and Nursing interview

During assessment what should the nurse look for when collecting data? Discrepancies

What is Maslow's Hierarchy of needs? non-nursing model that is holistic based used to help prioritize data collected.

The most basic need in Maslow's Hierarchy is? Physiologic

What are the 4 common assessment techniques? Inspection, Palpation, Percussion, Auscultation

Diagnosis is the? Is the Analysis of assessment data to form a suitable nursing diagnosis

Nursing diagnosis focuses on? signs and symptoms, effects of disease

A medical diagnosis focuses on the__________ of the disease. Pathophysiology

What are the 5 types of nursing diagnoses? Risk (potential), Actual, Possible, Wellness, and Syndrome

An actual diagnosis is/ The problem that exists

Syndrome diagnosis is a diagnosis that involves? A series of Dx. that usually occur together

A wellness diagnosis is used when there is no present illness but, the pt. is? Ready to move to a new level of wellness

Define Etiology. - Cause of the Problem

What is the basic format for a diagnosis statement? P.E.S. (Problem r/t Etiology as evidenced by S/S)

ADL's promote what for a patient? Self-esteem, Independence, Promote increased activity

What are 4 features common to the assessment process? collecting data, ongoing and systematic, categorization of data, recording data

Guidelines for delegation are set by what act in Oklahoma? Oklahoma Nurse Practice Act

Define a Risk Diagnosis. is an evaluation of a problem that could happen, also known as a potential diagnosis.

Define a Possible Diagnosis. it is when intuition leads the nurse to suspect a problem

Diagnostic Reasoning happens in the format of? Assessment Data, Clustering Data, Identifying Inconsistencies, Draw Conclusions

Personal hygiene is influenced by? Personal Preference, Culture and Religion, Economic Status, Developmental level, and Knowledge

Chain of Infection is a continuous cycle, the levels include? Infectious agent, Reservoir, Portal of Exit, Mode of Transmission, Portal of Entry, Susceptible Host

The most prevalent cause of accidental death in the U.S. across the lifespan is? MVC ( motor vehicle crash)

Older adults (65+ y/o) have a higher risk for what accidental injury? Falls

Once a patient has had a fall they are? Automatically at risk for a fall

Safety is part of the _________ level of Maslow's Hierarchy of Needs. Physiologic

Excoriation is? The breakdown of tissue due to compacted fecal matter.

When excess moisture is present due to diaphoreisis or urine, it can lead to? Maceration or breakdown of the skin