Deck 02_Nursing Process

Question 1

• Identify and define components of nursing process.

Answer 1

1. Assess- evaluate patient’s condition
2. Diagnose- identify the patients problems
3. Plan- set goals of care and desired outcome
4. Implement- perform the nursing actions identified in planning
5. Evaluation- determine if goals are met and achieved

Question 2

Identify and define three types of nursing diagnoses.

Answer 2

• Actual (problem focused)- undesirable human response to health problem that has been validated
• Risk diagnosis- vulnerability to health conditions/ life processes
• Health promotion- motivation and desire to increase well being and to actualize human health

Question 3

What are the components of actual and at-risk nursing diagnoses?

Answer 3

1. Actual
2. Actual —First two parts:
   
   1. Patient’s problem
   2. “related to” - Related factor, at-risk populations, associated conditions
3. Actual —Third part:
   
   • “as evidence by (AEB)” - defining characteristics
   • Excess Fluid volume related to excess sodium intake AEB edema (2+lower extremities)
4. At Risk–Only two parts:
   
   1. Patient’s problem
   2. “related to” - Related factor, at-risk populations, associated conditions

• Risk for falls related to acute illness

Question 4

How do you prioritize nursing diagnosis?

Answer 4

• Maslow’s Hierarchy of Human Needs
  
  • Physiological
  • Safety
  • Need for love, affection, belongings
  • Need for Esteem
  • Need for Self-actualization
• Patient Preference
• Anticipation of future problems

Question 5

What is the difference among nurse-initiated, physician-initiated, and interdependent nursing interventions?

Answer 5

1. Nurse can do this independently
   
   1. Monitor health status
   2. Reduce risk
   3. Resolve, prevent, or manage problem
   4. Facilitate independence or assist with activities of daily living
   5. Promote optimal sense of physical, psychological, and spiritual well-being.
   6. Nurse initiated interventions do not require a physician’s order
   7. Derived from the nursing diagnosis
2. Physician-initiated Interventions: Doctors Orders
   
   1. Orders that the physician has put in place (e.g., treatment, OT, PT orders)
3. Interdependent Nursing Intervention: Both Doctors and Nurses work together
   
   • Multiple disciplines (Nurses and Doctors) working together to provide the best plan of care to the patient.
   • Example: Nurse notices that patient has a fever but no medication to control it. They contact the Physician about the issue. The Physician prescribes medications to control the fever.