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Nursing Fundamentals: The Nursing process (ATI) Study Guide 2022

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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 car [Show More]

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