2.
Discuss the fundamental elements of the
Scientific Nursing Process
Name the various patient records
Discuss the principles of effective record
keeping
4.
What: Systematic and continuous collection
and interpretation of data relating to patient
When: within 2 hours
Who: RN/ EN under supervision
Types of data: Subjective/ objective
Sources of data: File, interview, physical
exam, family, previous records, test results,
multi-professional team
5.
Privacy, quiet – no interruptions
Comfort, no pain
Sit next to patient
Friendly and professional
Confidentiality
Low authority
Personal space
Use most reliable source
Do not repeat
Understandable
Language
No personal opinions
6.
Level of dependency
Actual + potential problems
Basic needs
◦ Breathing, eat and drink, elimination, mobility and
comfort, rest and sleep, clothing, hygiene, safety,
communication, religion, work, learning, play/
relaxation
7.
Compiling objectives and interventions to
◦ Supply basic needs of patient
◦ Solve problems
◦ Prevent possible complications
Patient Care Plan
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◦
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Prioritise
Goal/ expected outcomes
Discuss with patient
Record
9.
What should be continuously recorded?
◦
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Patient complaints
Observations
Nursing interventions
Abnormalities reported
Health education
Safety
Care plan adapted/ continued
10.
Continuous comparison of patient’s condition
with set objectives/ goals
Evaluate whether the patient’s condition is
improved
Evaluate the quality of nursing care
Final evaluation= cancellation of care plan