UTHSCSA N3802 Nursing Process
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| What is Assessment? | gathering and collecting patient information
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| What is Diagnosis? | identifying the patient’s problem
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| What is Planning? | setting goals and identifying appropriate nursing actions
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| What is Implementation? | performing nursing actions identified in planning
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| What is Evaluation? | determining if goals are achieved
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| When is the nursing process completed? | it is a continuous process, Evaluation is Assessment again
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| What are some critical thinking skills? | interpretation, analysis, evaluation, inference, explanation, self-regulation
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| What are some critical thinking attitudes? | confidence, thinking independently, fairness, responsibility and authority, risk taking, discipline, perseverance, creativity, curiosity, integrity, humility
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| What are the 2 phases of assessment? | collection of data and clustering data, recognizing patterns, and data analysis
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| What is subjective data? | information reported by the patient in their own words
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| What is objective data? | data that is measured or observed by a health care professional
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| What is more important subjective or objective data? | neither
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| What are 4 data sources? | the patient, family, other providers, medical record
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| What is the best source of data? | the patient if cognant and alert
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| What are 2 ways data can be clustered? | Gordon’s 11 Functional Health Patterns or by body systems
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| What are Gordon’s 11 Functional Health Patterns? | Health Perception/Health Management; Nutrition/Metabolic; Elimination; Activity/Exercise; Sleep/Rest; Cognitive/Perceptual; Role/Relationship; Sexuality/Reproductive; Coping/Stress Tolerance; Value/Belief
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| What are the 7 body systems? | respiratory, cardiovascular, nervous, gastrointestinal, musculoskeletal, genitourinary, integument
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| On what basis are nursing action or interventions based? | nursing diagnosis
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| What are defining characteristics of a diagnosis? | the cluster of signs and symptoms associated with the diagnosis
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| What is the etiology of a diagnosis? | related factors; factors that cause or contribute to the problem
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| What is an actual diagnosis? | clinical judgment that can be validated by the presence of defining characteristics; it is actually happening now
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| What are the parts of the actual nursing diagnosis? | label, etiology, signs and symptoms
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| How is an actual diagnosis written? | label R/T etiology (secondary to…) AEB signs/Symptoms
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| What is a risk diagnosis? Clinical judgment that an individual is more vulnerable to develop the problem |
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| What is the difference between nursing interventions for a risk diagnosis vs an actual diagnosis? | nusing interventions are aimed at prevention for risk diagnoses
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| What are the parts of the risk diagnosis? | label, etiology
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| How is a risk diagnosis written? | Risk for label R/T etiology
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| What are 5 sources of diagnostic errors? | errors in data collection, interpretation, data clustering, diagnostic statement, or premature closure before gather enough information
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| What are some rules to remember in writing diagnostic statements? | Only NANDA labels, use “related to” not “caused by,” make sure label and etiology do not restate each other, etiology is not a medical Dx, “secondary to” can be a medical Dx, don’t make judgmental statements, don’t suggest others not doing job
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| What are the stages of Maslow’s Hierarchy? | physiological needs: O2, fluids, food, temp, elim, shelter, sex, physical and psychological safety, love and belonging needs, self-esteem needs, self-actualization
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| How can priorities of different diagnoses be established? | use Maslow’s Heirarchy
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| What are the guidelines for writing goals? | ”the patient will…”, 1 goal per diagnosis, realistic, measurable, time limited, mutual, short or long term, can have multiple outcomes
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| What is included in a goal statement? | who, what behavior, how measured, when
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| What are guidelines for writing nursing actions/interventions? | ”the nurse will…”, based on etiology, based on rationale, generally focused on promoting, maintaining, or restoring health
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| What are 3 categories of nursing actions? | independent (nurse initiated), dependent (physician initiated), collaborative (requires knowledge, skill, and expertise of multiple health care professionals)
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| What are 3 types of independent nursing actions? | diagnostic, therapeutic, educational
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| What are 5 things it takes to be competent in the nursing process? | Be a critical thinker; Experiential & theoretical knowledge; Interpersonal communication skills; Technical skills; Willingness & Ability to Care
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