The Nursing Process
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| Describe Assessment | Two parts:
1.) Gather subjective& objective data
2.) Validate& interpret info gathered
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| Describe Diagnosis | Identifying the patients problems
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| Describe Planning | 1.) Set realistic goals of care & desired outcomes
2.) Identify appropriate nursing actions
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| Describe implementation | 1.) Performing the nursing actions identified in planning
2.) Carrying out care plan
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| Describe evaluation | Determine if goals and expected outcomes are achieved
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| What are some benefits of using the nursing process for the patient | Helps patient have a better understanding of what is going on; Gives patient an idea of what is expected out of them; Helps build and promote active involvement; Builds trust relationships
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| What are some benefits of using the nursing process for health care providers | A way to stay organized; contributes to documentation; Helps focus on patient needs; Provides common language for practice; Builds trusting relationships
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| How does the nursing process provide a framework for accountability and responsibility | Forces you to make responsible choices b/c you will be held accountable for your patients plan of action and the care received
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| What is the purpose of assessing? | Gathering all subjective and objective data possible and ensuring its accuracy to be able to use to formulate an efficient plan of care
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| What is an initial comprehensive assessment? | Basic head to toe; quick run-through of entire body
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| What is a partial/ time lapsed/ ongoing assessment? | A reassessment of something pre-existing issue
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| what is a focused or problem oriented assessment? | Focusing on a specific problem; COLDSPA
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| What does COLDSPA stand for? | Character; Onset; Location; Duration; Severity; Pattern; Associated Factors
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| What is subjective data | Information the patient/family/friends gives you
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| What is objective data | Information YOU observe; Facts; NO OPINIONS
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| What is an inderective approach to interviewing | Asking patient open ended questions; allow them to elaborate; build relationship
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| What is a directive approach to interviewing | Asking patient closed ended question; yes or no; helps narrow down possible issues; gets to the point
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| List advantages for indirective approach | Better understand patient issues; allows them to engage; builds relationship between patient and nurse
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| List disadvantages for indirective approach | Patient can get off topic; too much elaboration leads to irrelevant info
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| List advantages of directive approach | You can make quicker diagnosis; helps focus on issue
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| List disadvantages of directive approach | Patient can feel unimportant; causes patient withdrawal; could lose patient interest
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| What are some important aspects when conducting a patient-centered interview | being prepared; being organized; setting the stage; set an agenda; collect assessment/ nursing health history; terminating interview (summarize)
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| What are common health areas the nurse assesses | objective/subjective data; take account of health history
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| Why is it important to make an assessment in order to form a diagnosis | Must have accurate info in order to form a diagnosis...duh
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| What is a medical diagnosis | Identification of a disease or condition based on a specific evaluation of physical signs, symptoms, history, result of diagnostic tests or procedures; Doctor is only one qualified to make this diagnosis
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| What is a nursing diagnosis | Clinical judgement about individual/family/community; response to actual and potential health problems
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| What is the relationship between critical thinking and making nursing diagnosis | It is necessary to be thorough, comprehensive, and accurate when identifying nursing diagnosis that apply to your patient
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| What are the three parts of writing a nursing diagnosis | P.E.S: Problem, Etiology/related factors, Symptoms/defining characteristics
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| What are characteristics of a proper nursing diagnosis | Includes all 3 parts; organized; no blank spaces; proper initials& role/position stated; documenting for yourself only; keep confidential
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| What are common errors made when collecting data | lack of knowledge or skill; inaccurate data; missing data; disorganization
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| what are common errors made when interpreting data | inaccurate interpretation of cues; failure to consider conflicting cues; using insignificant number of cues; using unreliable or invalid cues; failure to consider cultural influences or developmental stage
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| What are common errors made when clustering data | insignificant cluster of cues; premature/ early closure; incorrect clustering
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| What are common errors made when labeling data | wrong diagnostic label selected; evidence that another diagnosis is more likely; condition of a collaborative problem; failure to validate nursing diagnosis with patient; failure to seek guidance
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| What are essential aspects of the planning stage | setting priorities; identifying patient centered goals/ expected outcomes; prescribing individualized nursing interventions; collaborate with patient/family/other healthcare professionals
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| Why is it important to coordinate a plan of care for the patient and family? | To ensure plan is implemented so patient has the best chance possible at moving towards a full recovery
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| What are some criteria used in priority setting | Urgence& importance:
(High/life threatening), intermediate (non life threatening), low (effects patient future while being not directly related to illness)
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| When considering Maslow hierarchy of needs what requires top priority | The bottom level; or basic needs of an individual are top priority; as you move up the levels they go down in ranking
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| What is the purpose of establishing client goals? | To achieve the highest level of wellness and independence; realistic and based on patients needs
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| What is the difference between goals and outcome criteria? | Goals are broad statements that describe a desired change and a patients condition/behavior. Expected outcome is measurable criteria to evaluate goal achievement
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| What are guidelines for writing SMART goals/ outcome criteria | Patient centered; singular goal/outcome; observable; measurable; time limited; mutual factors; realistic
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| What are essential guidelines for writing nursing care plans | Generally includes: diagnosis, goals/expected outcomes, specific nursing interventions, and a section for evaluation findings
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| What is a nurse initiated intervention | Independent nursing intervention/actions a nurse initiates
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| What is a physician initiated intervention | Dependent on nursing interventions, actions that require an order from a physician or another healthcare provider
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| What is a collaborative intervention | Interdependent interventions; therapies that require combined knowledge, skill and expertise of healthcare professionals
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| what are protocols | systematically developed set of statements that help nurses, physicians, and other healthcare providers make decisions about appropriate healthcare problems/ conditions
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| what are standing orders | pre printed document containing orders for the conduct of routine therapies monitoring guidelines and/or diagnostic procedures for specific patients with identifying clinical problems
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| What are essential guidelines for implementing nursing strategies? | include reassessing patient, reviewing/revising existing nursing care plan, organizing resources& care delivery, anticipating& preventing complications, implementing nursing interventions
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| What are the components of the evaluation process | Two components:
1.) Examination of a condition or situation
2.) judgement as to whether change has occurred
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| What is the relationship between critical thinning and evaluation | must apply critical thinking to make clinical decisions, and redirect nursing care to best meet patient needs
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| Discuss the use of standards of nursing care to evaluate responses to interventions | Used to determine whether the right interventions have been chosen or whether additional ones are required
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| Discuss how evaluation can lead to discontinuation, revision, or modification of a health care plan | If goals are met you may discontinue care; if goals are not met what so ever, or condition worsens patient needs to be reassessed and a new plan of action must be created; if change takes place and improvement is evident slight revisions may be made
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Created by:
amandamarie194
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