FON NURSING PROCESS Flashcards
The practice of nursing requires _________ and ___________
critical thinking and clinical reasoning.
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
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
combines both thinking and decision-making in the clinical
setting.
Critical Reasoning
SHE originated the term nursing process in 1955
Lydia Hall
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)
Collecting, organizing, validating, and documenting client data
ASSESSING
To establish a database about the client’s
response to health concerns or illness and
the ability to manage healthcare needs
ASSESSING
Analyzing and synthesizing data
Diagnosing
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
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
To develop an individualized care plan that
specifies client goals or desired outcomes
and related nursing interventions
PLANNING
Carrying out (or delegating) and documenting the planned nursing interventions
IMPLEMENTING
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
To determine whether to continue, modify,
or terminate the plan of care
EVALUATING
Measuring the degree to which goals or
outcomes have been achieved and identifying factors that positively or negatively
influence goal achievement
evaluating
ASSESSING
* C
* O
* V
* D
- Collect data
- Organize data
- Validate data
- Document data
DIAGNOSING
* A
* I
* F
- Analyze data
- Identify health problems,
risks, and strengths - Formulate diagnostic
statements
PLANNING
* P
* F
* S
* W
- Prioritize problems/diagnoses
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions
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
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
it is a continuous process carried out during all phases of the
nursing process.
ASSESSING
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
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.
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
- Actual Diagnosis
- Health Promotion Diagnosis
- Risk Nursing Diagnosis
- 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:
- Analyze the data
- Identify health problems
- 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
- Deficient
- Impaired
- Decreased
- 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)
- Problem
- Etiology
- Signs and Symptoms
Components of NANDA Nursing Diagnosis: 2 Parts (Use for risk and syndrome)
- Problem
- Etiology
Components of NANDA Nursing Diagnosis: 1 Part (Use for health promotion)
- Problem
Tips to minimize diagnostic
error
- Verify
- Build a good knowledge base and acquire
clinical experience - Have a working knowledge of what is normal
- Consult resources
- Base diagnosis on patterns/behavior over time
rather than an isolated incident - 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
- Initial Planning
- Ongoing Planning
- 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
- Prioritize problems
- Formulate goals/desired outcomes
- Select nursing interventions
- Write nursing interventions on care plans
Types of Nursing Care Plan
- STANDARDIZED
- 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
- Date and sign the plan.
- Use category headings.
- Use standardized/approved medical or English symbols and key words.
- Be specific
- Tailor the plan to the unique characteristics of the client by ensuring that the client’s choices are included.
- Ensure that the NCP incorporates preventive and health maintenance aspects as well as restorative ones.
- Ensure that the plan contains ongoing assessment of the client.
- Include collaborative activities in the plan.
- 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:
- Reassessing the client
- Determining the nurse’s need for assistance
- Implement the NI
- Supervise the delegated care
- 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
