Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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organized
systematic
problem-solving
decision-making
scientifically
philosophically
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cyclic
ongoing
dynamic
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organize
promote
restore
maintain
developed
communicated
needs
review
revise
validate
guide
omissions
conclusions
framework
problems
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strengths
goals
interpersonal
technical
intellectual
communicating, listening, conveying interest, compassion,
knowledge, and information, as well as developing trust and
obtaining data in a manner that enhances dignity of the client
use of equipment, performing procedures
analyzing, problem solving, critical thinking, and making judgments
coordinate
promote
universally applicable
quality of care is improved
promotes continuity of care
promotes high level of client participation
delivery of care and problem solving are organized, continuous, and
systematic
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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time and resources are utilized more efficiently
promotes delivery of care meeting expectations of both the health
care consumer and standards of the nursing profession
holds all nurses accountable and responsible for assessment,
diagnosis, planning, implementation, and evaluation of client care
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interview, physical assessment – a variety of sources are utilized,
i.e., client, family, diagnostic results, chart, etc.
validating the data will help prevent omissions, misunderstanding,
and incorrect inferences
categorizing or identifying patterns in the data
initial inferences or impressions
recording or reporting data
observable
measurable
description
perception
feelings
emotions
concerns
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physician
nurse
clinical
judgment
human
responses
response
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actual
risk
prioritizing nursing diagnoses
identifying short- and long-term goals and expected outcomes
determining nursing interventions that will aid in resolution or
prevention of each problem
intended
desired
change
cause
effectiveness
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planned
implemented
execution
performed
negative
putting the care plan into action
assessing, reporting, documenting
carrying out planned interventions
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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met
partially
met
not
met
decision
making
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analyzed
critical
thinking
problem
solving
decision
making
thought
validate
evaluate
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incomplete
cyclic
ongoing
systematic
scientifically
scientific
rationale
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data
collected
organized
interpreted
verified
validated
foundation
collected
analyzed
verified
organized
interpreted
initial
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actual
potential
overall
health
status
interview
examination
communication
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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documentation
enters
interview
observations
examination
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complement
clarify
support
confirms
investigate
understand
primary
source
nursing
records
medical
records
consultations
diagnostic
results
literature
remember
organize
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all aspects of the client’s physical, emotional, social, spiritual, and
economic well-being are collected and considered
observation
interview
examination
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appearance
behavior
physical
emotional
moods
interaction
social
cultural
understand
transmit
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look, listen, feel, smell
thin, obese, well-groomed; does client look his or her stated age?
Observe facial expression, how client is sitting. Is client making eye
contact? Note posture
How close are you?
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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receive
specific
purpose
facts
information
therapeutic
social
strategies
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active listening, conveying acceptance, being attentive, sitting eye
level with the client, if possible, and establishing eye-to-eye contact
privacy
time
noise
distractions
elaborate
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yes-or-no
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additional
relevant
information
summarizes
collect
data
baseline
direct
validation
clarification
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observation
use a penlight or natural or artificial lighting to enhance inspection
maintain privacy during inspection and be sensitive to the client’
feeling of embarrassment
communicate inspection techniques to the client to reduce anxiety
listening
touch
texture
temperature
moisture
location
size
detecting a lump, detecting conditions of the skin, e.g., moisture,
dryness, skin temperature
quality of a pulse, capillary refill, skin turgor assessment, assessing
for edema
to assess deep internal organ anomalies, abnormal response to pain
tapping
fingertips
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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fist
hammer
omissions
inconsistencies
inaccuracies
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information
inconsistencies
relatedness
patterns
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organizes
relatedness
confirmation
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analysis
problem
identification
nursing
diagnosis
analyze
organize
interpret
problems
potential
problems
physician
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does
not
change
required
second
step
diagnosis
label
holistic
scientific
knowledge
insight
critical
thought
classification
system
response
actual signs and symptoms are exhibited
possible
developing
problems
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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change
improves
resolves
worse
complement
separate
distinct
independent
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exists
support
presence
signs
symptoms
possible
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problem
etiology
defining
characteristics
nursing
diagnosis
related
to
focus
cause
direction
related
factor
as
evidenced
by
signs
symptoms
manifested
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problem
risk
factor
no
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plan
optimum
improved
identifying priority problems and interventions
setting realistic goals and expected outcomes
determining appropriate nursing interventions and recognizing when
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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collaboration is necessary
speculating scientific rationales for each nursing intervention
communicating the proposed care plan through documentation
holistic
analyzes
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client has maintained optimal physical condition with exercise or diet
client exhibits healthy ways of coping in a crisis; one’s motivation to
be independent; demonstrates strong spiritual beliefs resulting in
inner peace
may possess personal family support; compliance with medical
treatment
improvement
preserving
adjustment
acceptance
adjustment
determine priority problems; establish goals and expected outcomes;
write goals and expected outcomes; plan interventions with scientific
rationale; communicate and document the plan
client
preferences
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sense
of
control
basic
physiological
needs
higher
level
needs
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goals
actions
guidelines which individualize nursing interventions
used to evaluate effectiveness of the nursing care plan
direction to the care plan
intent
desired
change
methods
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achieved
action
time
frame
measured
prevention
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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resolution
rehabilitation
change
in
behavior
hours
days
weeks
months
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progress
goal
achievement
subject, behavior, criteria of performance, & time frame
client
centered
client
seen
felt
heard
measured
level
behavior
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clarity
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action
resolution
activates
predictable
manner
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planned
resolution
prevention
when
how
often
duration
communicated
guidelines
realistic
values
beliefs
consequences
risks
independent, interdependent, & dependent
not
requiring
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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direction
regulated
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support
consultation
collaboration
requiring
an
order
elimination
prevention
reduction
etiology
etiology
managing the environment
promoting safety within the environment
promoting rest
reducing noise
maintaining cleanliness of the environment
maintaining environmental temperature
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expected
responses
underlying
reasons
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execution
evaluation
promotion
prevention
illness
restoration
health
care
planning
identification
sense
control
compliance
physical
assessment
communication
71
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analyze
reporting
recording
complete
data
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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description of client’s condition, physical assessment, nursing
interventions performed, and the client’s response to interventions
problems
interventions
evaluation
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focus
such as, impaired mobility
such as, description of a wound, or abdominal pain
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such as, ability to perform ADL’s
such as, labored respirations or experiencing chest pain
such as, debridement of a wound
such as, referral to home health care
assessment
condition
basic
change-of-shift
quick
reference
75
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verbal
communication
summarized
organized
recounted
76
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right
to
privacy
confidentiality
82
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effectiveness
nursing
care
quality
care
responses
if
how
well
expected
outcomes
goal
achievement
cyclic
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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ongoing
baseline
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behaviors
expected
goals
relationship
goal
judges
analysis
referral
consultation
collaboration
positive
negative
present
past
tense
84
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resolution
prevention
acceptance
purpose
response
goal
touch
sight
smell
hearing
reassessed
evaluated
change
status
behavior
specific
behaviors
time
frame
85
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progresses
higher
reactivate
reassessment
analyzed
organized
interpreted
identified
relabeled
etiology
compared
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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achievement
resolution
summarized
documented
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collection
verification
validation
organization
interpretation
documentation
interview
examination
review
comparison
assessment
health
care
statements
feelings
perceptions
concerns
observable
measurable
felt
complements
clarifies
physical
emotional
social
spiritual
economic
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developmental
data
clustering
relatedness
patterns
clustered
92
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verify
validate
organize
clusters
93
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compliment
clarify
critical
thought
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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documented
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analyze
organize
interpret
analyzed
interpreted
labeled
priority
problems
interventions
goals
expected
outcomes
interventions
scientific
rationale
communicating
documenting
95
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priorities
interview
assessment
goals
expected
outcomes
direction
focus
etiology
intent
change
subject
behavior
criteria
performance
time
frame
condition
realistic
96
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planned
executed
predictable
principles
knowledge
elimination
prevention
reduction
etiology
underlying
reason
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Nursing Process: Concepts and Application. Wanda Seaback. Delmar Publishers 2000.
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executed
assessment
evaluation
assess
data
database
execute
provided
ongoing
cyclic
98
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appropriateness
effectiveness
goal
attainment
revised
revisions
modifications
reactivated
reassessment
omissions
inaccuracies
discontinued
return
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