Ch. 5 Flashcards
What is the purpose of the nursing process?
Organizing the ways nurses think about patient care
A patient comes to the ER complaining about nausea and vomiting. What should the nurse ask the patient about first?
Severity and duration of the nausea and vomiting
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?
The patient
What is the primary reason of the nursing diagnosis?
Communicating patient needs
On what premise is a nursing diagnosis identified for a patient?
Clustered data
Which statement is an appropriately written short-term goal?
Patient will walk to the bathroom independently without falling within 2 days after surgery
What should be the primary focus for nursing interventions?
Patient needs
Which nursing action is critical before delegating interventions to another member of the health care team?
Know the scope of practice for the other team member
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
Identify reasons the patient is unable to sleep
What action should the nurse take regarding a patients plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
Monitor patient urine output to evaluate the need for the current plan of care
Define the nursing process
The nursing process is the scientific method through which professional nurses systematically identify and address actual or potential patient problems.
Critical thinking and the nursing process
allows nurses to collect essential patient data, articulate the specific needs of individual patients, and effectively communicate those needs of individual patients, and effectively communicate those needs, establish realistic goals and customize interventions with members of the health care team
Describe the historical development of the nursing process
The nursing process was clearly identified in the 1960s, and have remained unchanged since then - only added outcome identification in the 1990s
significance of the nursing process
Professional nursing practice in all types of settings is based on nursing process
Used to assess individuals, families and communities; diagnose needs; plan attainable goals; implement specific interventions; evaluate degrees of goal attainment
Articulate the characteristics of the nursing process
Requires nurses to think critically.
It is dynamic, organized and collaborative, and universally adaptable to various types of health care settings.
Assessment
Patient care data are gathered
Diagnosis
Patient data are analyzed to identify patient problems and then stated as specific nursing diagnoses
Planning
The nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification
Implementation
Initiating specific nursing interventions designed to help achieve established goals
Evaluation
The nurse determines goal attainment, the effectiveness of interventions and whether the plan of care should be discontinued, continued, or revised
Explain the significance of the cyclic and dynamic nature of the nursing process
Requires professional nurse to continuously reassess patients, revise care as needed, and evaluate whether goals are being met.
As goals are met, portions of the nursing plan can be eliminated or discontinued.
Nursing care sometimes needs to be modified to meet previously unidentifiable needs.
The ongoing process of evaluating and adjusting intervention strategies requires nursing care that is based on current EBP
Thinking like a nurse
Facilitated by nurses using the nursing process in the development of individualized patient plans of care.
Analytical
Is the data collection thorough and accurate?
Are outcomes specific and realistic for the individual patient?
Have all of the underlying factors contributing to the patients response to illness been adequately addressed in the plan of care?
Could any of the nursing interventions have a negative impact on the patient?
Does each intervention provide for patient-centered care and the safety of the patient?
Are there new data that necessitate modification of the existing plan of care?
The nursing process is cyclic
As an individual patients condition changes, so does the way a professional nurse thinks about the patients needs, forcing modification of earlier plans of care
Data collection
- primary data \+ patient interview - secondary data - subjective data \+ symptoms \+ health history - objective data \+ signs \+ physical examination \+ lab results \+ diagnostic test results
Types of nursing diagnoses
- actual
- risk
- health-promotion
Prioritize nursing diagnoses
- personalize care plans
+ short-term goals
+ long-term goals
+ outcome identification
Interventions
- independent
- dependent
- collaborative care
- direct
- indirect
Documentation (NIC)
- care plans
+ clinical pathways
+ protocols
+ standing orders
Care plan evaluation
- patient goal/outcome attainment?
- continue?
- revise/adapt?
- discontinue?
Collaborative
Collaboration among several members of the health care team is often required to adequately address patient needs
Adaptable
Developing plans of care for individuals who are hospitalized or are receiving care in an outpatient, long-term care, or home setting
Useful for addressing needs of a specific population (childhood obesity)
NANDA-I
Professional nursing org that provides standardized language to identify patient problems and plan customized care
Medical diagnoses
Labels for diseases
Nursing diagnoses
Describe a response to an actual or potential problem or life process
Actual nursing diagnoses
1) patients identified need or problem
2) etiology or underlying cause
3) signs and symptoms or manifestations
Risk nursing diagnoses
1) patients identified need or problem
2) factors indicating vulnerability (risk factors)
Health-promotion nursing diagnoses
1) nursing diagnostic label
2) defining characteristics
Clinical pathways, protocols, standing orders
Impact interventions carried out in the implementation phase of the nursing process
Clinical pathways
Care pathways, care maps, critical pathways
Multidisciplinary resources designed to guide patient care
Protocols
Written plans that can be generalized to groups of patients with the same or similar clinical needs that do not require a physicians order
Standing orders
Written by physicians and list specific actions to be taken by a nurse or other health care provider when access to a physician is not possible
(Chest pain, or after a colonoscopy.)
Ethical, legal, and professional practice
- all health care pros are required to document patient interventions they implement in a traditional or EMR
- nurses must document the physical treatment and patient education that is provided
- follow-up evals of interventions must be documented to help health care team determine the effectiveness fo treatments, activities and prescribed meds
- only document interventions that the nurse themselves implemented
