NURS-1056EL Lecture Notes - Lecture 5: Nursing Care Plan, Nursing Process
Document Summary
The nursing process is a systematic method that involves clinical decision making for individualized patient care. About the patient, helping with communications between the nurses because its going to focus on the patient. Could you move back and forth between steps? (potter and perry p. 153) Yes you can, you will be involved with the process. Nursing process (adpie) assessment evaluation diagnosis implementation planning. Asking the pt questions and actively listening. Getting to know the pt and their family or friends looking at information about the pt (lab results, vital signs, history) conducting physical assessments. Verbal descriptions of health subjective data (symptoms) non observable. Objective data (signs) are seen, heard, felt or smelled. Pulse beats 150 per minute, regular and strong. Purpose: identify the pt"s response or problem to an illness or situation. Kardex (pt data profile or care trends) Standardized care plans (where things could be added or deleted as the patient progresses)