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Fund Q3
Unit 5 - Nursing Process
| Question | Answer |
|---|---|
| The nursing process – definition and purpose | a framework for planning and providing nursing care, problem solving approach, is logical and purpose is to provide individualized client care |
| Purpose of each phase of the nursing process | Assessment: gathering facts. Diagnoses: statement regarding the nature of a phenomenon. Planning: determine end goal, design interventions. Intervention: Carry out plan. Evaluation: appraises care plan and begins nursing process again. |
| Nursing skills used and needed for each phase of the nursing process | Interpersonal, technical and intellectual |
| What are the phases of the nursing process? What is the purpose of each? How do they relate to each other? | ADPIE |
| Phases, and parts of each phase, of the nursing process | Assessment (facts) Diagnoses (id problem) Planning (what to do) Interventions (doings) Evaluation (did it work) |
| Accountability | the ability and willingness to assume responsibility for one's actions and to accept the consequences of one's behavior |
| Discharge planning | process of preparing a client to leave one level of care for another within or outside the current health care agent. |
| Which members of the health care team are responsible for all phases of the nursing process? | The RN's are responsible for writing, everyone for completing. |
| Types of assessments (4) | initial, focused, emergency and time-lapsed |
| What are various methods of data collection? | health hx, phys assessment, labs/diagnostic tests, material from other HCP |
| What are objective and subjective data? What are some sources of each? What skills does the nurse use to obtain both types of data? | 1. objective (measurable) signs 2. subjective (opinions and feelings) symptoms |
| Objective signs | (measurable) signs |
| Subjective symptoms | (opinions and feelings) symptoms |
| Data sources | primary and secondary (sign other, literature, client records) |
| Compare and contrast primary and secondary sources of data. Give examples of each. | client is always 1st source |
| Methods of data collection | observing, interviewing, and examining |
| What are the phases of an interview? What is done in each phase? | opening: sets the tone and establishes rapport, Body is working phase and closing is summarization/thank you. |
| Body systems model | integumentary to immune systems. System that MSTC uses however other approaches are there. (such as Wellness model) |
| Documentation of data | record in a factual manner, no interpretations. |
| Data base | all information about a client, includes nursing health hx, phys assessment, physician's history, phys exam and lab/diag test results |
| What is a nursing diagnosis? What is its value to nursing? How is it used? | Assessment data is interpreted to identify a client problem or potential problem. |
| Characteristics of a nursing diagnosis | RN must do this, id "health problem", in domain of nursing and judgement made through systematic data collection |
| What are the differences between a medical and nursing diagnosis? | medical describes a disease, treatable by md. Nursing describes a human response, treatable by nurse within scope/practice |
| Standing orders | Physician orders pre-established and approved for use by nurses and other professionals under specific conditions |
| Independent nursing functions | areas unique to nursing, do not need an order |
| Dependent nursing functions | need an order to proceed |
| What are the various types of nursing diagnoses? | Actual, Risk, Potential, Wellness and Syndrome |
| Actual and risk problems | actual (problem that does exist at the time of assessment) risk (problem that could develop) |
| What is P.E.S.? What is P.E.? When is each used? | Problem (diagnostic label/definition) Etiology (risk factors) and S (Signs/symptoms) |
| What are the three (or two) parts of a nursing diagnosis? | analyze and data processing, determine clients health problems, risks and strengths (weaknesses) formulated the diagnostic statement |
| What are data clusters? | cluster cues are a cue is significant if it points to a + or -, client change, varies norms of client population and indicates developmental delay |
| What are the purposes of care plans? | provides direction for individualized client care, provides continuity of care, direction for documentation/assessment, guide for assigning staff and guide for insurance reimbursement |
| What are the parts of the planning phase of the nursing process? | initial, ongoing and discharge |
| Protocols | preprinted actions commonly required for a particular group of clients |
| Standards of care | formal plan that specifies the nursing care for groups of clients with common needs. |
| Nursing interventions – and be able to correctly state | specific actions the nurse and nursing staff takes to help client meet the established client goals, written during planning stop, carried out during implementation step |
| What are the guidelines for writing an accurate nursing diagnosis? | specific, inc preventative health, teaching, health maint and restorative, include collaborative activities/coordination, include discharge plans, refer to procedures rather than including all steps, and includes interventions for ongoing assessment |
| Components of the nursing intervention | date written, action verb, conditions/modifiers, time element for event to occur-how long-when-how often to be done, and signature of nurse writing |
| How does the nurse set priorities? | client's health values/beliefs, client priorities, resources available, urgency of health problem and medical treatment plan |
| What is priority setting? At what part of the nursing process is it performed? Why? | Planning phase. client's health values/beliefs, client priorities, resources available, urgency of health problem and medical treatment plan |
| Prioritization of goals | clients health values and beliefs, client priorities, resources available to nurse/client, urgency of health problem and medical treatment plan. |
| What is the difference between goals and desired outcomes? | Goals--broad. Outcomes-specific. |
| What are LTG and STG? What phase of the nursing process do they occur? How are they determined? How are they different? | Long Term Goal/Short Term Goal. STG is stepping stone to LTG, and LTG is guide to discharge and long term planning |
| Long-term goals – and be able to correctly state | example: guide discharge and long term planning: the client will walk unassisted with a cane by discharge by 8-10 |
| Short-term goals – and be able to correctly state | example: stepping stone to LTG: the client will walk with crutches with assistance by 3 days after surgery by 7-28. |
| How does the nurse set independent and cooperative priorities? | SMART. Specific. Measurable. Attainable. Realistic. Timely. |
| Considerations of implementation (8) | based on scientific knowledge, clearly understands interventions, individualizes activities for client, safe care, provides teaching/support/comfort, holistic care, respect client's dignity and increase self esteem, courage client participation |
| What are components of the evaluation phase of the nursing process? What is done in each step? | reassesses to see if the plan of care is effective, look at outcomes to determine goal attainment, problem is either resolved or not resolved, and decision is made to continue the current plan or modify the plan. |
| Types of evaluation | ongoing, intermittent and terminal |
| Principles for goal/desired outcome writing | identify client goals, collect data related to goals, compare current data with desired outcomes, relate nursing activities to client outcomes, continue/modify/or terminate nursing care plan |
| What if the goals/desired outcomes are not met? What does the nurse do? | re-evaluate and start nursing process again. |
| How is an evaluation statement written? | goal met, goal partially met or goal not met. |
| What are the components of goals/desired outcome statements and how are they written? | conclusion + supporting data = evaluation statement |
| Be able to correctly write an evaluation statement example: | Client goal: The client will drink 2400 ml for 2 days by 2/15. Evaluation statement: Goal met: client drank 3000 ml q 24 hours for two days. |
| Accountability is a critical aspect of nursing care. An example of a specific decision-making process of accountability is demonstrated by: | Evaluating the client's outcomes after implementation of care |
| The nurse is working with a client who is being prep for a diag test this aft. The client tells the nurse she wants to have her hair shampooed. Which of the following is the most appropriate label with regard to assigning priority for her request? | Low priority |
| Nursing interventions should be documented according to specific criteria so they are clearly understood by other members of the nursing team. The most appropriate of the following intervention statements is: | This intervention statement omits the method. |
| A nurse who specializes in care of clients with ostomies shows a client's significant other how to assist with the manipulation of ostomy equipment. The nurse is demonstrating the technique to the client is using what type of nursing skill? | Psychomotor |
| During an interview, the nurse needs to obtain specific information about the signs and symptoms of a health problem. To obtain these data most efficiently, the nurse should use: | Closed-ended questions |
| After visiting with the client the nurse documents the assessment data. Both objective and subjective information has been obtained during the assessment. Which of the following is classified as subjective data? | States feels anxious and tense |
| The nurse uses a variety of skills in the application of the nursing process. An example of a cognitive nursing skill is: | Recognizing the potential complications of a blood transfusion |
| Nursing diagnoses must meet specific criteria to reflect both the client's problem and the possible etiology involved. Which of the following is an appropriate etiology for a nursing diagnosis? | Incisional pain |
| Nursing interv should be documented w/ specific crit so they are understood by other members of the nursing team. The intervention statement “Nurse will apply warm, wet soaks to the client's leg while the client is awake” lacks which components? | Frequency |
| Nursing diagnoses meet specific criteria so they accurately reflect both the client's problem and the possible etiology involved. Of the following statements, which one is an example of an appropriately written nursing diagnosis? | Deficient knowledge related to need for cardiac catherization |
| The nurse notes a narcotic is to be administered per epidural cath. The nurse, however, does not know how to perform this procedure. Which aspects of the implementation process should be followed? | Seek assistance |
Created by:
mstcnurse