Nursing Fundamentals: The Nursing process (ATI) Study Guide 2022.
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Course
Nursing
Institution
Nursing
what is the nursing process? - a cyclical, critical thinking process.
it is dynamic, continuous, client-centered, problem-solving, and decision making framework that is
foundational to the nursing practice.
five steps of the nursing process - 1. assessment/data collection
2. analysis
3. plan...
and decision making framework that is foundational to the nursing pr
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Nursing Fundamentals: The Nursing
process (ATI) Study Guide 2022
what is the nursing process? - a cyclical, critical thinking process.
it is dynamic, continuous, client-centered, problem-solving, and decision making framework that is
foundational to the nursing practice.
five steps of the nursing process - 1. assessment/data collection
2. analysis
3. planning
4. implementation
5. evaluation
methods of data collection - 1. observation
2. interviews
3. medical history
4. comprehensive or focused physical exam
5. diagnostic and laboratory reports
6. collaboration
what is involved in collecting data effectively? - 1. ask appropriate questions
2. listen carefully to responses
3. develop good head to toe assessment skills
4. employ critical thinking and clinical judgment
5. recognize the need to collect data prior to interventions
when do you collect subjective data (symptoms)? - during the nursing history
what does subjective data include? - 1. symptoms
, 2. patients feelings
3. patients perceptions
4. description of health status
when is objective data (signs) obtained? - during the physical assessment
how do nurses obtain objective data? - "nurses feel, see, hear, and smell objective data through
observation or physical assessment of the client"
primary sources of data - this is what the patients tells the nurse (subjective) or what the nurse
observes.
secondary sources of data - what others tell the nurse based on what the client has told them
(subjective; "she told me that her shoulder is sore every morning") and the objective data is obtained
from another source such as, family, friends, health care professional, or records.
what three things does the nurse do during assessment? - 1. validate
2. interpret
3. cluster data
analysis - use of critical thinking to identify health status or problems, interpret, or monitor the collected
data base, reach an appropriate nursing judgment about health status and coping mechanisms, and
provide direction for nursing care.
what does analysis requires the nurse to do ..? - 1. recognize patterns or trends
2. compare the data with expected standards or reference pages
3. arrive at conclusions to guid nursing care
documentation - documentation is essential. it should focus on facts and should be very descriptive.
what does planning involve? - 1. establish priorities and outcomes that can be measured and evaluated
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