Lecture 6 - The Nursing Process Flashcards
What are the two professional nursing organizations in Canada?
–> Canadian Nurses Association (CNA)
–> Canadian Nurses Protective Society (CNPS)
What is the role of professional nursing organizations in Canada?
To serve as official representative of the nursing profession and interact with government officials on issues concerning the health of a population.
What is the professional regulatory body for Canadian nurses?
College of Nurses of Ontario (CNO)
Which professional union exists for all Canadian nurses?
Canadian Nurses Association (CNA)
What is critical thinking?
A process and set of skills, includes the use of knowledge and reasoning to make accurate clinical judgements and decisions.
What are the steps of a critical thinking process?
–> Recognizing the client’s health problem or concern
–> Analyze data
–> Review assumptions and evidence
–> Explore alternative solutions and prioritize the client’s preferences
–> Consider ethical principles
–> Draw conclusions on how to proceed
What is basic critical thinking?
–> Thinking is concrete and based on a set of rules or principles
–> Rigid, black and white thinking with little flexibility for patient preferences or comfort
What is complex critical thinking?
–> Begin to separate one’s own thinking from those of other experts
–> Realize that alternative and conflicting solution to a problem can exist - one must weigh the benefits and risk.
What is the commitment level of critical thinking?
When one anticipates the need to make choices without assistance from other professionals, then assumes responsibility and accountability to those choices.
What are the five components of critical thinking?
–> Specific Knowledge base
–> Experience
–> Competencies
–> Attitudes
–> Standards
The analysis of data, the diagnosis, etiologies, current plans, and implemented interventions are part of which step in the nursing process?
Evaluation
Data analysis, problem identification, and label are part of which step in the nursing process?
Diagnosis
Priority and goal setting is part of which step in the nursing process?
Planning
Nurse-initiated and physician initiated treatments are part of which step in the nursing process?
Implementation/intervention
Subjective and objective data are part of which step in the nursing process?
Assessment
What is nursing assessment?
The systematic and deliberate collection of data to determine a client’s current and past health status and functional status to determine the client’s present and past coping patterns.
What are primary sources of information?
The client
What are secondary sources of information?
–> Family and significant others
–> Health care team
–> Medical records
What are tertiary sources of information?
–> Literature
–> Nurse’s experience
What is the first step in a nursing assessment?
The Interview
–> Introduce oneself, and explain role as HCP
–> Establish therapeutic relationship
–> Obtain Insight about client’s concerns or worries
–> Determine the client’s goals and expectations
–> Obtain cues about what may require furthur assessment
What is the second step in a nursing assessment?
Collecting Health History
–> Bio
–> AMPLE
–> Psychological, spiritual, sociocultural, developmental variables
–> Current state of health and reason for interview
What is the third step in nursing assessment?
Physical Assessment
What is done during data analysis and interpretation?
Data validation and recognition of patterns and trends.
Comparing with normal trends is also helpful.
All of this is needed for appropriate clinical decision making
What is the purpose of a nursing diagnosis?
To determine the client’s health problems that are within the domain of nursing, in order to decide what care the client should receive
What is the difference between a medical and nursing diagnosis?
A medical diagnosis is the identification of a disease condition based on specific evaluation of signs and symptoms
A nursing diagnosis is a clinical judgement about a client’s response to an actual or potential health problem
What is a collaborative problem?
An actual or potential complication that nurses monitor to detect a change in the client status
What is NANDA? What is their mission?
North American Nursing Diagnosis Association
–> Mission is to facilitate the development, refinement, dissemination, and use of the standardized nursing terminology
What is NANDA’s purpose?
–> TO determine precise definitions and a common language among the profession
–> To allow for clear communication
–> To distinguish the nurse’s role
What is an Actual Nursing Diagnosis?
One that describes responses to health conditions or life processes that exist in an individual, family, or community
What is a Risk Nursing Diagnosis?
One that describes responses to health conditions of life processes that may develop.
What is a Health Promotion Nursing Diagnosis?
A clinical judgement of a person’s family’s or community’s motivation and desire to increase well-being by readiness to enhance specific health behaviours, such as nutrition and exercise
What is a Wellness Nursing DIagnosis?
One that describes the levels of wellness in an individual, family, or community that can be enhanced.
What is the difference between a health promotion nursing diagnosis and a wellness nursing diagnosis?
A wellness nursing diagnosis describes wellness that can be enhanced, whereas a health promotion diagnosis can be used in any state and no not necessarily reflect current levels of wellness.
The following statement is an example of which kind of nursing diagnosis?
Risk for infection related to a site for organism invasion secondary to surgery
Risk Nursing Diagnosis
What are the three components of an Actual Nursing Diagnosis?
Problem
–> From NANDA-I list)
Etiology
–>Related cause or contributor to the problem
Symptoms
–> As described by patient
[Diagnosis label] related to [Etiology] as evidences by [symptoms]
What are the two components of a Risk Nursing Diagnosis?
Diagnosis
–> Taken from official NANDA=I list
Related Factors
–> Risk factors
[Diagnosis Label] related to [Risk factor]
The following statement is an example of which kind of nursing diagnosis:
Acute pain related to stress on surgical area during movement as evidences by patient report, elevated heart rate, and BP
Actual Nursing Diagnosis
What is the only component of a health promotion or wellness nursing diagnosis?
The official label from NANDA-I list
The following statement is an example of which kind of nursing diagnosis:
Readiness for enhanced self-care
Health Promotion / Wellness
What is the difference between a goal and expected outcome?
A goal represents the predicted resolution of nursing diagnosis or health problem, whereas expected outcome is the measurable criteria to evaluate goal achievement.
These may be combined
What are the the three types of interventions?
Independent
–> Nurse initiated
Dependent
–> Physician initiated
Collaborative
–> Interdependent
Which six factors must be considered when selecting interventions?
- The nursing diagnosis
- Expected outcomes
- Evidence base for interventions
- Feasibility of the intervention
- Acceptability to the client
- Nurse’s competency
Who developed the Nursing Interventions Classification (NIC)?
The Iowa Intervention Project
What are four important components of the implementation step of the nursing process?
–> Reassessing the client
–> Reviewing and revising existing nursing care plan
–> Organizing resources and care delivery
–> Anticipating and preventing complications
What is indirect care? What are some examples?
Indirect care are actions that support the effectiveness of direct care intervention, such as:
–> Communicating nursing interventions
–> Documentation
–> Medical order transcription
–> Infection control
–> Computer data entry
–>Delegation, supervision, and evaluation of the work of staff members
What are the five elements of evaluation in nursing care?
- Identify evaluative criteria and standards
- Collect evaluate data
- Interpret and summarize findings
- Document findings and clinical judgements
- Terminate, continue, or revise the care plan.
