Collect data Organize data Validate data Document data

Analyze data Identify health problems, risks, and strengths Formulate diagnostic statements

Collect data related to outcomes Compare data with outcomes Relate nursing actions to client goals/outcomes Draw conclusions about problem status Continue, modify, or terminate the client’s care plan

FON NURSING PROCESS Flashcards by Karyl Cheska Bañadera

The practice of nursing requires _________ and ___________

critical thinking and clinical reasoning.

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is the process of intentional higher level thinking to define a client’s problem,
examine the evidence-based practice in caring for the client,
and make choices in the delivery of care.

Critical Thinking

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is
the cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of
the information, and decide on possible nursing actions to
improve the client’s physiologic and psychosocial outcomes.

Clinical Reasoning

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combines both thinking and decision-making in the clinical
setting.

Critical Reasoning

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SHE originated the term nursing process in 1955

Lydia Hall

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they were among the first 3 to use it to refer to a series of phases
describing the practice of nursing.

Johnson (1959), Orlando (1961), and Wiedenbach (1963)

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Collecting, organizing, validating, and documenting client data

ASSESSING

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To establish a database about the client’s
response to health concerns or illness and
the ability to manage healthcare needs

ASSESSING

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Analyzing and synthesizing data

Diagnosing

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To identify client strengths and health problems that can be prevented or resolved
by collaborative and independent nursing
interventions
To develop a list of nursing and collaborative problem

DIAGNOSING

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Determining how to prevent, reduce, or
resolve the identified priority client problems;
how to support client strengths; and how
to implement nursing interventions in an
organized, individualized, and goal-directed
manner

Planning

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To develop an individualized care plan that
specifies client goals or desired outcomes
and related nursing interventions

PLANNING

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Carrying out (or delegating) and documenting the planned nursing interventions

IMPLEMENTING

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To assist the client to meet desired goals
or outcomes; promote wellness; prevent illness and disease; restore health; and facilitate coping with altered functionin

implementing

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To determine whether to continue, modify,
or terminate the plan of care

EVALUATING

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Measuring the degree to which goals or
outcomes have been achieved and identifying factors that positively or negatively
influence goal achievement

evaluating

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ASSESSING
* C
* O
* V
* D

Collect data
Organize data
Validate data
Document data

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DIAGNOSING
* A
* I
* F

Analyze data
Identify health problems,
risks, and strengths
Formulate diagnostic
statements

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PLANNING
* P
* F
* S
* W

Prioritize problems/diagnoses
Formulate goals/desired outcomes
Select nursing interventions
Write nursing interventions

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IMPLEMENTING
* R
* D
* I
* S
* D

Reassess the client
Determine the nurse’s need for assistance
Implement the nursing interventions
Supervise delegated care
Document nursing activities

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EVALUATING
* C
* C
* R
* D
* C

Collect data related to outcomes
Compare data with outcomes
Relate nursing actions to client goals/outcomes
Draw conclusions about problem status
Continue, modify, or terminate the client’s care plan

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it is a continuous process carried out during all phases of the
nursing process.

ASSESSING

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A clinical judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group or community.

Diagnosis

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Purpose of Diagnosis

To identify client strengths and health problems that can be prevented or resolved by
collaborative and independent nursing interventions. To develop a list of collaborative and nursing
problems.

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To define, refine and promote a taxonomy of nursing diagnostic terminology for general use of professional nurses.

PURPOSE OF NANDA INTERNATIONAL

4 Types of Diagnosis

1. Actual Diagnosis 2. Health Promotion Diagnosis 3. Risk Nursing Diagnosis 4. Syndrome Diagnosis

client problem is present at the time of diagnosis.

Actual Diagnosis

relates to client’s preparedness to implement behaviors to improve their health condition

Health Promotion Diagnosis

is a clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene.

Risk Nursing Diagnosis

is assigned by a nurse’s clinical judgment to describe a cluster of nursing diagnoses that have similar interventions.

Syndrome Diagnosis

3 Main Activities performed in diagnosis:

1. Analyze the data 2. Identify health problems 3. Formulate diagnostic statement

Problem- Describes the client’s health problem or response to a health status clearly and concisely in a few words.

TRUE

DXTIC labels need to be specific. * Deficient Knowledge (Specify) * Deficient Knowledge ( TB Medications)

TRUE

Problem Qualifiers

1. Deficient 2. Impaired 3. Decreased 4. Ineffective

inadequate amount, quality, not sufficient, incomplete

Deficient

made worse, weakened, damage, reduced, deteriorated

Impaired

lesser in size, amount or degree

Decreased

not producing the desired effect

Ineffective

Identifies one or more probable causes of health problem, gives direction to the required nursing therapy and enables the nurse to individualize the client’s care.

Etiology

The cluster of signs and symptoms that indicate the presence of a particular diagnostic label.

Signs and Symptoms

client’s signs and symptoms

ACTUAL NDX

no subjective and objective data

RISK NDX

* Compare data against standards * Cluster or group data * Identify gaps and inconsistencies

Activities

* Finding patterns and relationships among cues * Making inferences * Suspending judgment when lacking data * Stating the problem * Examining assumptions * Comparing patterns with norms * Identifying problems contributing to the problem

Critical Thinking Activities

Components of NANDA Nursing Diagnosis: 3 Parts (Use for actual problem)

1. Problem 2. Etiology 3. Signs and Symptoms

Components of NANDA Nursing Diagnosis: 2 Parts (Use for risk and syndrome)

1. Problem 2. Etiology

Components of NANDA Nursing Diagnosis: 1 Part (Use for health promotion)

1. Problem

Tips to minimize diagnostic error

1. Verify 2. Build a good knowledge base and acquire clinical experience 3. Have a working knowledge of what is normal 4. Consult resources 5. Base diagnosis on patterns/behavior over time rather than an isolated incident 6. Improve critical thinking skills

is the deliberate process of identifying nursing interventions to prevent, reduce or eliminate the client’s nursing problem.

Planning

Types of Planning

1. Initial Planning 2. Ongoing Planning 3. Discharge Planning

The comprehensive plan initiated by the nurse during the first contact with the patient.

Initial Planning

Change made in the plan of care as the nurse evaluates the client’s response to care or as new data is collected and a new diagnosis is formulated

Ongoing Planning

The process of anticipating and planning for self-care and continuity of care after a patient leaves a HC setting.

Discharge Planning

Purposes of Planning

*To determine whether the client’s status has changed. *To set priorities for the client’s care. *To decide which problems to focus on during the shift. *To coordinate the nurses’ activities..

Activities in Planning

1. Prioritize problems 2. Formulate goals/desired outcomes 3. Select nursing interventions 4. Write nursing interventions on care plans

Types of Nursing Care Plan

1. STANDARDIZED 2. INDIVIDUALIZED

formal plan that specifies the nursing care for group of clients with common needs.

STANDARDIZED

is tailored to meet the unique needs of a specific client- needs that are not addressed by the standardized plan.

INDIVIDUALIZED

Guidelines for Writing a NCP

1. Date and sign the plan. 2. Use category headings. 3. Use standardized/approved medical or English symbols and key words. 4. Be specific 5. Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices are included. 6. Ensure that the NCP incorporates preventive and health maintenance aspects as well as restorative ones. 7. Ensure that the plan contains ongoing assessment of the client. 8. Include collaborative activities in the plan. 9. Include plans for the client’s discharge and home care needs.

Types of Nursing Interventions

Independent Dependent Collaborative Interventions

activities that are nurses are licensed to initiate on the basis of their knowledge and skills. a. Physical care b. Environmental management c. Ongoing assessment d. Referrals e. Emotional support f. Comfort measures g. Teaching h. Counseling

Independent

activities carried out under the orders or supervision of a licensed physician. a. Admin. Of meds. b. IVF c. Diagnostics d. Diet e. Treatment f. Activity

Dependent

actions the nurse carries out in collaboration with other HCPs. a. Diet b. Rehabilitation c. PT/OT d. Ventilatory Management

Collaborative Interventions

-Prioritize problems -Formulate goals/desired outcomes -Select nursing -interventions -Write nursing interventions on care plans

Activities

Forming valid generalizations Transferring knowledge from one situation to another Developing evaluative criteria Hypothesizing Making Interdisciplinary connections Prioritizing problems Generalizing principles from other sciences

Critical Thinking Activities

is the action phase in which the nurse performs the nursing interventions and document the care needed.

Implementation

What are the 3 implementing skills

-Cognitive skills -Interpersonal skills -Technical skills

include problem solving, decision-making, critical thinking, clinical reasoning and creativity.

Cognitive skills

includes all activities, verbal and non-verbal, people use when interacting directly with one another.

Interpersonal skills

are purposeful “hands-on” skills that require knowledge and manual dexterity

Technical skills

Process of Implementing:

1. Reassessing the client 2. Determining the nurse’s need for assistance 3. Implement the NI 4. Supervise the delegated care 5. Document the interventions performed

GUIDELINES IN IMPLEMENTATION:

* Base NI on scientific knowledge, nursing research and professional standards of care. * Clearly understand the NI to be implemented and question any that are not understood. * Adapt activities to the individual client. * Implement SAFE CARE. * Provide teaching, support and comfort. * Be holistic. * Respect the dignity of the client and enhance the client’s self-esteem. * Encourage the client to participate actively in implementing NI.

is the a planned, ongoing and purposeful activity to determine the client’s progress, the achievement of the goals and the effectiveness of the nursing care plan

Evaluation

Activities in Evaluation

In evaluation, the nurse reassess the client to collect data to compare it against the desired outcome, draw conclusion of the problem status and determine the next course of action- continuing the plan, modifying or terminating the plan.

Types of evaluation

-Structure Evaluation -Process Evaluation -Outcome Evaluation

focuses on the setting in which care is given. It answers this question: What effect does the setting have on the quality of care? Structural standards describe desirable environmental and organizational characteristics that influence care, such as equipment and staffing.

Structure evaluation

focuses on how the care was given. It answers questions such as these: Is the care relevant to the client’s needs? Is the care appropriate, complete, and timely? Process standards focus on the manner in which the nurse uses the nursing process. Some examples of process criteria are “Checks client’s identification band before giving medication” and “Performs and records chest assessment, including auscultation, once per shift.”

Process Evaluation

focuses on demonstrable changes in the client’s health status as a result of nursing care. Outcome criteria are written in terms of client responses or health status, just as they are for evaluation within the nursing process. For example, “How many clients undergoing hip repairs develop pneumonia?” or “How many clients who have a colostomy experience an infection that delays discharge?”

Outcome Evaluation