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NUR151-NursProcess
Nursing Process - ADPIE
| Question | Answer |
|---|---|
| evidence-based knowledge | knowledge based on research or clinical expertise, makes you an informed critical thinker. |
| diagnostic reasoning | a process of determining a client's health status after you assign meaning to the behaviors, physical signs, and symptoms presented by the client. |
| Inference | the process of drawing conclusions from related pieces of evidence involves forming patterns of information from data before making a diagnosis |
| Clinical decision making | a problem-solving activity that focuses on defining client problems and selecting appropriate treatment |
| The nursing process is often called | a blueprint or plan for client care. |
| Five components of critical thinking | knowledge base, experience, critical thinking competencies (with emphasis on the nursing process), attitudes, and standards. |
| ___ is a process acquired through experience, commitment, and an active curiosity toward learning. | Critical thinking |
| ___ involves judgment that includes critical and reflective thinking and action and application of scientific and practical logic. | Clinical decision making |
| The nursing process is | a blueprint for client care that involves both general and specific critical thinking competencies in a way that focuses on a particular client's unique needs. |
| What is Nursing? | blend of science & art – all integrated in one – must be strong in bio and sciences to understand what is happening with your patient |
| Art component is | Care of others – sympathetic, knowledge to do health promotion, educating the patients |
| How does nursing process differ from medical practice? | Medical practice focuses on the illness, where we as nurses focus on the client and their response to the illness. |
| Assessment | gather data |
| Diagnosis | ID problem – Formulate Nursing Diagnosis |
| Planning | Write care plan to meet goals – what we want the patient to achieve – document the plan Identify goals & Desired Outcomes, Plan Interventions |
| Implementation | carry out a plan – steps to help them to obtain those goals. |
| Evaluation | Collective objective data to determine the extent to which goals were achieved. Plan as needed. – Very important to know if plan needs to be reevaluated. Area missed often by nurses. |
| The nursing process is also | a client-centered, goal-oriented method of providing care |
| Nursing process is Involves | developing plan of care based on an assessment of client needs |
| According to JCAHO, care must be? | documented according to the Nursing Process, be goal-directed, Multidisciplinary problem list for each client, Individualized plan of care for each client, and nuse must document results of care plan, progress toward goals |
| Individualized care plan | specifically designed for a specific client. |
| Standardized care plan | “clinical pathway” – based on a medical diagnosis or illness – everyone with that condition has the same plan. Can be modified slightly, but not too much. |
| Preparatory care plan | more detailed than other Care plans – this is what we as students do and it prepares student to provide safe care and stimulates critical thinking |
| Clinical pathways or Critical pathways | Tool to coordinate care, multidisciplinary treatment plan that outlines treatments or interventions for specific condition - e.g. Client with congestive heart failure |
| Assessment | Systematic data collection to determine client needs - Current & past health status, Meds, Functional status, Coping patterns, Response to therapy – how well are they responding, risk for potential problems, desire for higher level of wellness and willing |
| The purpose of assessment is to | establish a database about the client's perceived needs, health problems, and responses to these problems. |
| Effective communication | requires verbal and nonverbal skills – don’t put back to patient |
| Systematic Observation | involves looking at patient and determining what it contributing to their problem? What is the potential cause? |
| Accurate Interpretation of Data | look at their objective symptoms |
| Standardized nursing diagnoses | NANDAs |
| NANDA | North American Nursing Diagnosis Association - developed standard language, Currently more than 150 diagnoses, Written by nurses |
| Choose appropriate NANDAs (nursing diagnoses) based on | Assessment data and Presence of major defining characteristics |
| What is the purpose of Nursing Diagnosis? | Identify & label client responses to health problems holistically – trying to help the whole person and not just their illness–meets need for common, consistent language, Basis for choosing nursing interventions – based on the diagnoses. |
| What defines body of knowledge for which nurse is held accountable. | NANDAs - Define our interventions and set us apart from medical “physician” care. |
| Actual nursing diagnosis | have defining characteristic (signs and symptoms) – can see sign and symptom now – actually exist - impaired gas exchange as ID by low O2 level. Using assessory muscles. |
| Risk for or potential diagnosis | things they are at risk for – risk factors are evident but no signs or symptoms evident yet – will possibly develop - at risk for skin breakdown because they are on bedrest. |
| Health promotion diagnosis | increase a patient’s well being and compliance |
| Wellness diagnosis | if they are willing to be compliant. |
| Diagnostic statement has | 3 or 4 parts – (1) NANDA – what diagnosis is most appropriate, (2) Related to (R/T) – etiology/cause of prob, (3)Secondary to (S/T) medical dx (Optional), and (4) As evidenced by (AEB) or AMB – must be related to the NANDA - Major defining characteri |
| For an accurate diagnosis, you must have | signs and symptoms to back it up. |
| Related to | Condition or etiology which can be changed by nursing intervention - Indicates etiology which contributes to NANDA - May be Pathophysiological component – biological or psychological, Treatment-related, Situation, Maturational |
| Example of actual diagnosis written as a 3 or 4 part statement | Impaired physical mobility R/T (related to) pain, decreased strength & endurance S/T (secondary to) fractured hip AEB (as evidenced by/as manifested by) inability to ambulate, turn, or transfer independently. |
| Health Promotion/Wellness Diagnosis | Client must express desire for improved well-being, willingness to make changes-Write as single statement (E.g. Readiness for enhanced nutrition or readiness for enhanced comfort) |
| Actual diagnoses usually take priority over | Risk for dx |
| Risk for diagnosis take priority over | a wellness dx |
| A nursing diagnosis is | a clinical judgment about individual, family, or community responses to actual and potential health problems or life processes. It is a statement that describes the client's actual or potential response to a health problem that the nurse is licensed and c |
| A collaborative problem is | an actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status – ie hemorrhage, infection, and cardiac arrhythmia. |
| The diagnostic process flows from | the assessment process and includes decision-making steps. These steps include data clustering, identifying client needs, and formulating the diagnosis or problem. |
| Defining characteristics | the clinical criteria or assessment findings that support an actual nursing diagnosis. |
| Clinical criteria | objective or subjective signs and symptoms, clusters of signs and symptoms, or risk factors that lead to a diagnostic conclusion. |
| diagnostic label | the name of the nursing diagnosis - describes pt. response to health conditions - include descriptors - ie. impaired physical mobility includes descriptor impaired to describe nature/change in mobility - Ex compromised, decreased, deficient, delayed, effe |
| Related factor | a condition or etiology id from the pt assessment data - associated w/pt actual or potential response to health problem - can change by using nursing interventions. |
| Related factors for NANDA-I diagnoses include four categories | pathophysiological (biological or psychological), treatment-related, situational (environmental or personal), and maturational |
| The etiology of the nursing diagnosis is always within | the domain of nursing practice and a condition that responds to nursing interventions. |
| Nursing actions __ affect the medical diagnosis | do not |
| Give 3 examples of errors in diagnostic statements | Not a scientifically based diagnosis – needs to be precise & appropriate, (2) Id pt problem rather than the nursing intervention, (3) Make professional rather than prejudicial judgments. |
| Constipation (NANDA) | R/T poor fluid intake, decreased mobility, and narcotic use, AEB c/o (complains of) hard stools (subjective), difficult to pass (subjective), decreased bowel sounds (objective), abdomen distended (objective). |
| AEB not needed for | Risk diagnoses |
| RUMBA | R – Realistic and able to be measured - is it realistic to have no pain in 1 hour? A better goal would be pain to be 5 out of 10., U - Understandable to client, M- Measurable – some form of measurement, B - Believable – patient has to believe in the goa |
| The advantage of a concept map is | its central focus on the pt rather than the disease or health alteration - encourages students to concentrate on pt specific health problems & nursing diagnoses. |
| Nursing diagnostic errors occur by | errors in data collection, interpretation and analysis of data, clustering of data, or in the diagnostic statement. |
| Goal is ALWAYS | a positive reflection of the problem or NANDA - State a realistic time frame to achieve goal |
| How would you write a goal statement for “Impaired physical mobility” | Client will demonstrate ability to turn from side to side within 24 hours |
| Interventions are actions performed | to resolve problem/ achieve client outcomes - based on clinical knowledge & judgment, research based, Nurse prescribed, May be Collaborative: Physician Prescribed, implemented by nurse - E.g. Administer medications, oxygen, wound care |
| Examples of highest priorities | risk for other-directed violence, impaired gas exchange, and decreased cardiac output are typically high-priority nursing diagnoses that drive the priorities of safety, adequate oxygenation, and adequate circulation. |
| Nurses exercise “cognitive shifts” | shifts in attention from one pt to another during conduct of the nursing process - occurs in response to pt needs changing, new procedures being ordered, or environmental processes interacting. |
| A goal is | a broad statement that describes the desired change in a client's condition or behavior. |
| expected outcomes | measurable criteria to evaluate goal achievement |
| Goals and expected outcomes serve two purposes | to provide clear direction for the selection and use of nursing interventions and to provide focus for evaluating the effectiveness of the interventions. |
| Goals and outcomes need to meet | established intellectual standards by being relevant to client needs, specific, singular, observable, measurable, and time-limited. |
| A client-centered goal is | a specific and measurable behavior or response that reflects a client's highest possible level of wellness and independence in function. Ex “Client will perform self-care hygiene independently” and “Client will remain free of infection.” |
| A goal contains only one | behavior or response. The example of “Pt will administer a self-injection & demonstrate infection control measures” is incorrect because the statement includes two different behaviors, administer and demonstrate. |
| Always write expected outcomes | sequentially, with time frames |
| nursing-sensitive client outcome | an individual, family, or community state, behavior, or perception that is measurable along a continuum in response to a nursing intervention. |
| There are seven guidelines for writing goals and expected outcomes. The guidelines are | client-centered, singular, observable, measurable, time-limited, mutual, and realistic. |
| There are three categories of nursing interventions | nurse-initiated, physician-initiated, and collaborative interventions. |
| Independent nursing interventions do not require | a physician’s order – autonomous – education, elevating foot, etc. |
| Dependent nursing interventions require? | a physician’s order – administering meds, invasive procedure, changing dressing, etc. |
| NIC model | nursing interventions classifications |
| The NIC model includes three levels | domains, classes, and interventions for ease of use. |
| Domains | the highest level (Level 1) of the model, using broad terms (e.g., safety and basic physiological) to organize the more specific classes and interventions. |
| The second level of NIC model includes | 30 classes, which offer useful clinical categories to refer to when selecting interventions. |
| The third level of NIC model includes | 542 interventions, defined as any treatment based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes |
| Critical pathways | multidisciplinary treatment plans that outline the treatments or interventions clients need to have while they are in a health care setting for a specific disease or condition. |
| Most critical pathways are based on | medical diagnoses and not nursing, but the related nursing diagnoses common to a medical problem and the associated nursing interventions are incorporated. |
| A critical pathway | maps out day to day or even hour to hour the recommended interventions and expected outcomes for a client. |
| During planning | determine client goals, set priorities, develop expected outcomes of nursing care, and develop a nursing care plan. |
| Interventions are for | ONE PROBLEM ONLY! Must relate back to NANDA & Goal |
| Nursing Interventions | Assessment, therapeutic nursing, educational, referral |
| Assessment | Interventions regarding what will be assessed – ex: impaired oxygenation – one of those assessments would be to auscultate their lungs every 4 hours, evaluate their labs every morning, monitor I/O, assess pulse oximetry every hour. |
| Therapeutic Nursing Interventions | What can you do to help the client overcome the problem addressed in your nursing dx? – must be specific so next nurse can follow |
| Intellectual | Knowledge, judgment |
| Interpersonal | Communication, emotional support, promote client dignity & respect |
| Technical skills | clinical skills, equipment management |
| Cognitive | Critical thinking ability |
| information passed in shift report is | the pertinent information about the client. Abnormal labs, diagnostic tests, how they responded to the treatments, etc. |
| nursing intervention | any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance client outcomes |
| Direct care interventions | treatments performed through interactions with clients. For example, a client receives direct intervention in the form of medication administration, insertion of an intravenous infusion, or counseling during a time of grief. |
| Indirect care interventions | treatments performed away from the client but on behalf of the client or group of clients |
| Clinical guideline or protocol | document that guides decisions & interventions for specific health care problems - developed on the basis of an authoritative examination of current scientific evidence and assists nurses, physicians, and other health care providers in making decisions ab |
| Standing order | preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for specific pt w/identified clinical problems. |
| Five preparatory activities include | reassessing the client, reviewing and revising the existing nursing care plan, organizing resources and care delivery, anticipating and preventing complications, and implementing nursing interventions. |
| A primary nurse is accountable for | the nursing care a client receives during his or her length of stay. |
| A team nurse is accountable for | the care a client receives for a specific shift in which the nurse works. |
| Psychomotor skills require | the integration of cognitive and motor activities – ex giving an injection -need to understand anatomy & pharmacology (cognitive) and use good coordination and precision to administer the injection correctly (motor). |
| Lifesaving measures | include administering emergency medications, instituting cardiopulmonary resuscitation, intervening to protect a confused or violent client, and obtaining immediate counseling from a crisis center for a severely anxious client. |
| You conduct evaluative measures to determine | if you met expected outcomes, not if nursing interventions were completed. |
| Examples of nursing-sensitive outcomes include | reduction in pain severity, incidence of pressure ulcers, and incidence of falls. |
| When you achieve outcomes | the related factors for a nursing diagnosis usually no longer exist. |
| The purposes of NOC (nursing outcome criteria) are | (1) to identify, label, validate, and classify nursing-sensitive pt outcomes; (2) to field test and validate the classification; and (3) to define and test measurement procedures for the outcomes and indicators using clinical data. |
Created by:
Ladystorm