NSG 252 Chapter Notes - Chapter 16: Nursing Process, Critical Thinking, Medical Record
Document Summary
Nsg process: systematic and rational method of planning and providing client centered care. Provides a framework for a nurse responsibility and accountability. Interrelated, more than on phase may be involved at any one time. Purpose for nsg pro(cid:272)ess: to ide(cid:374)tify a (cid:272)lie(cid:374)t"s health status a(cid:374)d a(cid:272)tual or pote(cid:374)tial health (cid:272)are pro(cid:271)le(cid:373)s or needs, to establish plans to meet the identified needs, and to deliver specific nursing interventions to meet those needs. Nursing process steps: assessment, gather i(cid:374)for(cid:373)atio(cid:374) a(cid:271)out the patie(cid:374)t"s (cid:272)o(cid:374)ditio(cid:374, diagnosis/analysis. Ide(cid:374)tify the patie(cid:374)t"s pro(cid:271)le(cid:373)s: planning, set goals of care and desired outcomes and identify appropriate nursing actions. Implementation: perform nursing actions identified in planning, evaluation, determine if goals and expected outcomes are achieved. Assessment (step 1): systematic collection of data relating to clients. Two steps: collection of information from primary source and secondary sources. Data collections: performing assessment to gather info needed to make and a(cid:272)(cid:272)urate judg(cid:373)e(cid:374)t a(cid:271)out a pt. "s (cid:272)urre(cid:374)t (cid:272)o(cid:374)ditio(cid:374)
