Subjective Information - What the client tells you
Objective Information - What you measure or observe
Open Ended Questions - Allows for the collection for more information for the client to elaborate on their symp
...
Subjective Information - What the client tells you
Objective Information - What you measure or observe
Open Ended Questions - Allows for the collection for more information for the client to elaborate on their symptoms or concerns.
Closed Ended Questions - Allows for a yes or no answer only
Genogram - Method of visually portraying family relationships and medical history to see trends
Therapeutic Communication - a way to communicate with patients and staff while respecting values
Databases - helps us assess, track, see labs and notes, and give medications. allows nurses to make clinical judgments and be organized
Cultural Competency - respecting all areas of culture and respecting values of patients specific to culture
Steps of the Nursing Process - Assessment
Diagnosis
Outcome Identification
Planning
Implementation
Evaluation
Assessment - Collecting data from medical record, health history, physical exam, functional assessment, risk assessment while using evidence based practice
Diagnosis - Compare clinical findings with normal and abnormal variations and developmental events. interpret data and create hypothesis and nursing diagnosis
Outcome Identification - Identify expected outcomes, individualize to the person, culturally appropriate, realistic and measurable, include a timeline
Planning - Establish priorities, develop outcomes, set timelines for outcomes, identify interventions, integrate evidence based practice
Implementation - Must be done in a safe and timely manner using evidence based practice. Coordinate care and collaborate with other while giving treatment.
Evaluation - Progress towards outcomes. Must be systemic and ongoing. Can be revised and must include patient and family.
[Show More]