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Nursing Process
NP1, Unit 1 Nursing Process Lecture
| Question | Answer |
|---|---|
| The Practice of Professional Nursing | Performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill. Includes observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care. |
| Nursing Process - Definition | Organized, systematic method of giving individualized care. Thinking/doing approach that nurses use in their work. |
| Purpose of the nursing process | Helps ensure that clients receive best possible nursing care by: ID'ing client's health status and actual or potential health problems Establishing plans to meet ID'd needs. Delivering specific nursing interventions to meet ID'd needs. |
| The nursing process is the framework for nurse's _______ and ______. | Accountability and responsibility |
| Nursing Process - Benefits for client | Continuity of care Prevents omission of care and unnecessary repetition of care Individualized Increased client/family participation |
| Nursing process - benefits for the nurse | Self confidence Job satisfaction Fosters inquiry and continual learning Aids in appropriate staff assignments Promotes collaboration and understanding within the profession Promotes individualized care Promotes efficiency |
| Steps of the Nursing Process | Assessment Diagnosis Planning Implementing Evaluating |
| Each step of the nursing process depends on the ______ of the previous step | Accuracy. |
| Because each step depends on the previous steps, the entire process depends on the accuracy and thoroughness of the ____ step, ______. | First, assessment |
| Qualities of the Nursing Process | Dynamic and cyclic Client-centered Planned and outcome-directed Flexible Universally applicable cognitive process |
| Nursing Process Relies On | Interpersonal skills Technical skills Creativity and curiosity Adaptability Intellectual Skills (Critical Thinking) |
| Qualities of Critical Thinkers | Inquisitive Systematic Analytical Judicious Open-minded Confident in reasoning |
| Assessment | Data collection, organization, validation, documentation. |
| T or F - Assessment documentation should include the nurse's interpretations of the data | False. No interpretive statements should be included. |
| Organization of data means: | Putting like data together. |
| Critical thinking skills for assessment | Observe Distinguish relevant from irrelevant data validate data organize data categorize data |
| Data must be: | Descriptive, concise, complete, and without interpretive statements. |
| Sources for data include: | client history (via interview or chart) Physical exam Lab and radiology data |
| Holistic assessment should include: | Physiological, psychological, sociocultural, developmental, and spiritual assessments. |
| Subjective data | ONLY what the client tells you. Client's thoughts, feelings, beliefs, sensations, perceptions. Perceived and verified only by the client. |
| Objective data | Observed by others, measured, written as a "cue". EVERYTHING other than what client says. |
| Cue | What we see, hear, feel, smell, and measure (assessment facts without interpretation). |
| Inference | Judgment or interpretation of what the cue means. DO NOT DO THIS. |
| What are ways to ensure that data is complete and accurate? | Recheck own data Check for temporary factors that might alter data Recheck extremely abnormal data. Have someone else collect same data. |
| Diagnosis involves: | Analyzing data, identifying health problems, risks, and strengths. Formulating diagnostic statements. Diagnosis can be of an |
| The Practice of Professional Nursing | Performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill. Includes observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care. |
| Nursing Process - Definition | Organized, systematic method of giving individualized care. Thinking/doing approach that nurses use in their work. |
| Purpose of the nursing process | Helps ensure that clients receive best possible nursing care by: ID'ing client's health status and actual or potential health problems Establishing plans to meet ID'd needs. Delivering specific nursing interventions to meet ID'd needs. |
| The nursing process is the framework for nurse's _______ and ______. | Accountability and responsibility |
| Nursing Process - Benefits for client | Continuity of care Prevents omission of care and unnecessary repetition of care Individualized Increased client/family participation |
| Nursing process - benefits for the nurse | Self confidence Job satisfaction Fosters inquiry and continual learning Aids in appropriate staff assignments Promotes collaboration and understanding within the profession Promotes individualized care Promotes efficiency |
| Steps of the Nursing Process | Assessment Diagnosis Planning Implementing Evaluating |
| Each step of the nursing process depends on the ______ of the previous step | Accuracy. |
| Because each step depends on the previous steps, the entire process depends on the accuracy and thoroughness of the ____ step, ______. | First, assessment |
| Qualities of the Nursing Process | Dynamic and cyclic Client-centered Planned and outcome-directed Flexible Universally applicable cognitive process |
| Nursing Process Relies On | Interpersonal skills Technical skills Creativity and curiosity Adaptability Intellectual Skills (Critical Thinking) |
| Qualities of Critical Thinkers | Inquisitive Systematic Analytical Judicious Open-minded Confident in reasoning |
| Assessment | Data collection, organization, validation, documentation. |
| T or F - Assessment documentation should include the nurse's interpretations of the data | False. No interpretive statements should be included. |
| Organization of data means: | Putting like data together. |
| Critical thinking skills for assessment | Observe Distinguish relevant from irrelevant data validate data organize data categorize data |
| Data must be: | Descriptive, concise, complete, and without interpretive statements. |
| Sources for data include: | client history (via interview or chart) Physical exam Lab and radiology data |
| Holistic assessment should include: | Physiological, psychological, sociocultural, developmental, and spiritual assessments. |
| Subjective data | ONLY what the client tells you. Client's thoughts, feelings, beliefs, sensations, perceptions. Perceived and verified only by the client. |
| Objective data | Observed by others, measured, written as a "cue". EVERYTHING other than what client says. |
| Cue | What we see, hear, feel, smell, and measure (assessment facts without interpretation). |
| Inference | Judgment or interpretation of what the cue means. DO NOT DO THIS. |
| What are ways to ensure that data is complete and accurate? | Recheck own data Check for temporary factors that might alter data Recheck extremely abnormal data. Have someone else collect same data. |
| Diagnosis involves: | Analyzing data, identifying health problems, risks, and strengths. Formulating diagnostic statements. Diagnosis can be of an actual problem or a risk for a problem. |
| Diagnosis | Second step in nursing process Statement about client's present health status. Describes actual or potential problem that nurses can LEGALLY diagnose and prescribe the PRIMARY treatment and prevention measures. |
| NANDA | North American Nursing Diagnosis Association. Defines, refines, promotes a taxonomy of nursing diagnostic terminology of general use to professional nurses. Currently more than 150 approved nursing diagnoses. |
| Structure of an actual nursing diagnosis | Problem related to etiology AMB signs and symptoms. |
| Structure of a risk-for nursing diagnosis | Problem related to etiology |
| True or False - In a nursing diagnosis, the etiology is the client's medical diagnosis. | False. The etiology is NEVER the medical diagnosis. However, a step may be added to include medical diagnosis - problem r/t etiology SECONDARY TO MEDICAL DX amb signs and symptoms. |
| How should a nurse prioritize nursing diagnoses? | Based on preservation of life, Maslow's hierarchy of needs, and client preferences. |
| Planning | Involves setting goals for the client and interventions for the nurse that are backed by rationales. |
| Purposes of the Goal | The desired outcome of the nursing interventions. Guide planning of care Gives criteria for evaluation of progress. |
| Qualities of a good goal statement: | Begin with The client will... Realistic for individual client Designated time span. Compatible with therapies of other professions. Directly related to nursing dx Use observable, measurable terms for outcomes. Client values goal, consider it impo |
| Types of goals | Short term Long term Ongoing Discharge goal |
| Components of a goal statement | Subject (the client) Action verb (will lose) performance criteria (1 pound) Target time (by 5/25) Special conditions* (wearing same clothes as 5/24) *special considerations are optional. |
| Nursing orders and their purpose | Written detailed instructions for nurses to follow Must be interpreted correctly by all caregivers Guide implementation and documentation of care. Measure nurse's accountability. |
| Guidelines for writing nursing orders | Review Nursing Dx Review client goal ID Alternative Actions Use Principles and theories from nursing and related courses for ideas for nursing actions. Think of all possible activities to achieve the goal. Include preventions as interventions. |
| Consideration for Obtaining a Consultant/the Consultation Process | Identify general problem Obtain appropriate professional Provide pertinent resources Do not bias consultant Be available to discuss findings. Add recommendations to care plan. |
| T or F - When forming nursing orders, you should consider what orders have been successful in the past. | True. |
| T or F - Because the nursing orders are the responsibility of the nurse, it isn't important to consider the client's knowledge, abilities, or resources. | False. These things should be a consideration in forming nursing orders. |
| T or F - Nursing orders don't have to directly address the cause of the problem. | False. Orders should address the cause of the problem. |
| T or F - Nursing orders should be congruent with client's values, beliefs, and cultures. | True. |
| T or F - Nursing orders should be based on nursing knowledge, experience, and relevant sciences. | True. |
| T or F - Nursing orders should be within the standards of care. | True. |
| Components of a nursing order. | Subject (nurse, but do not write, "The nurse will", this is understood). Action verb - what the nurse will do. Descriptive qualifiers - how or what and where to perform action. 4. Specific times - when, how often, how long, specific dates and times. |
| Three categories of nursing orders | Assessment Decrease stressors/strengthen lines of defense Teaching/counseling/referring |
| Rationale | Scientific reasoning for selecting a specific nursing action. |
| Process of Implementation | Determine nurse's need for assistance. Coordinate with other aspects of care, explaining interventions to patient. Communicate the nursing actions. Assign interventions as appropriate. Document implementation and client response. |
| T or F - It is OK to delegate interventions to PCA if they are within the PCA's scope of practice. | True. |
| T or F - The nurse should attempt to carry out an intervention he or she does not feel prepared to perform. | False. If you feel that specifics of a plan are above your skill level, you should have plan reviewed by qualified resource person or instructor. |
| T or F - The nurse should perform interventions that are inconsistent with his or her ethical or moral beliefs. | False. First, have the plan reviewed by qualified resource person or instructor. |
| Documentation of implementation | Who performed the care Which orders were actually implemented. Client's response to care. |
| Evaluation | How well did the plan work? Are changes needed? Determination of whether the client goal was met, not met, or partially met. Includes comparison of observed results with outcome criteria found in client goal statement. |
| Components of evaluation | Collect data related to desired outcomes. compare the data to desired outcomes. Relate nursing activities to outcomes. Draw conclusions about problem status. Continue, modify, or terminate the nursing diagnosis. |
| Evaluative Statement | Two parts: 1. Judgment about whether client goal was met. 2. Data to support judgment (actual observation of client behavior) including the date/time evaluated. IS NOT an evaluation of the nursing orders/actions! |
| Reference List | List of sources used in APA format. |
Created by:
christyness
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