Lesson 3 - The Nursing Process Flashcards
The Nursing Process
-ongoing (cyclical) process used with every patient interaction
Nursing Process Characteristics
-client-centered
-focuses on problem solving and decision making
-collaborative
-uses critical thinking
Purpose of the Nursing Process
-gather data (ie. by interview, chart, environment)
-cluster data (ie. by body system or hierarchy of needs)
-engage in critical thinking and clinical reasoning
-make decisions
-plan and evaluate care
Step 1: Assessment
-collect, organize, validate, document data
-results in comprehensive understanding of patient situation
-holistic: past and present health status
Initial Assessment
-explores presenting problem and contributing factors
-physical assessment
-health history
-psychosocial assessments
Focused Assessment
-gathers specific details about presenting concern
-confirms or rules out abnormalities
Time-lapsed Assessment
-reevaluate status
-has condition improved, worsened, or remained?
Emergency Assessment
-ensure ABCs (airway, breathing, circulation)
-identify primary cause of problem
Expected Findings Before Nursing School
-world view
-previous experiences
-culture, religion, family, friends
-K-12 knowledge
Expected Findings During/After Nursing School
-understanding other perspectives
-school and clinical experiences
-cultural humility
-interpersonal relationship knowledge
-nursing knowledge
Step 2: Nursing Diagnosis
-analyze data (significant vs. insignificant)
-identify problems, risks, strengths
-formulate diagnostic statements
-expected vs. unexpected findings
Step 3: Planning
-prioritize (Mazlows Hierarchy of Needs)
-goals/desired outcomes
-identify nursing interventions
Step 4: Implementation
-reassess patient
-determine need for assistance
-implement nursing interventions
-ensure interventions are in scope of practice
-document what you have done
-maintain safety
-teaching
Step 5: Evaluation
-collect outcome related data
-draw conclusions
-continue, modify, or end care plan
Interprofessional Teams (data sources)
-physicians (+ their notes)
-dietician
-PT
-OT
-spiritual caregiver
-social worker
Medical Record/Chart
-holds various info in the form of a patient “file”
-nursing documentation, medical records, progress notes, test/lab results, interdisciplinary team notes
Other sources of data
-books
-physical assessment
-patient and family
Health Interview
-opportunity for nurse and patient to exchange information and form a therapeutic relationship
-doesn’t always have to be formal
-trust, respect, genuine
Health Interview: Verbal Communication
-open + closed ended questions
-leading + neutral questions
-paraphrasing
-clarification
Health Interview: Nonverbal Communication
-facial expressions
-gestures
-posture
-attentiveness
Social Determinants of Health
-provide important context to life situations, health, relationships, outcomes, risks
Sight (Assessment Tool)
-skin tone/bruises
-abnormal movements
-consciousness level
-response to touch
Smell (Assessment Tool)
-unique smells
Touch (Assessment Tool)
-skin temp
-fluid volume (edema)
Sound (Assessment Tool)
-verbal
-body processes
Primary Data Sources
-patient
Secondary Data Sources
-family & friends
-environment
-records
-interprofessional team
-literature
Subjective Data
-based on feelings, opinions
Objective Data
-factual, measurable
-not based on opinion
Inference
-conclusion reached from evidence and reasoning
-confirm with patient
-look at other data to validate
Gordon’s Functional Health Patterns
-used to gather patient info and sort the data into categories
-ie. elimination, nutrition-metabolic, sleep-rest, role-relationship, etc.
Maslow’s Hierarchy of Needs
-from bottom (physiological needs) to top (self-actualization)
Physiological Needs (bottom)
-breathing, food, water, excretion
Safety
-security of body, employment, health, property
Love/belonging
-family and friends
-intimacy
Esteem
-confidence, respect, achievement
Self-actualization (top)
-morality
-creativity
-lack of prejudice
Nursing Diagnosis
-focus on human response to actual or potential health problems/quality of life
-within scope of practice
Medical Diagnosis
-focus on illness/medical problem
NANDA-I
-North American Nursing Diagnosis Association - International
-13 categories
-ie. nutrition, activity and rest, comfort, etc.
-use nursing diagnosis handbook
Steps to formulate Nursing Diagnosis
- Choose a NANDA-I label (actual/risk/wellness/syndrome)
- determine etiology (likely cause) of problem
- List manifestations (signs and symptoms) - not for RISK!
Initial Planning
-based on admission assessment
-directs patient care
Ongoing Planning
-continually changing plans based on response to care
-based on assessment and evaluation
Discharge Planning
-anticipate and plan for care needs when patient moves home or to another facility
Goals/Outcomes
-broad statements
-relate to nursing diagnosis
SMART Goals
-specific
-measurable
-achievable
-relevant
-timely
Independent Nursing Intervention
-nurse can accomplish without order from doc or np
Dependent Nursing Intervention
-based on doc orders
Collaborative Nursing Intervention
-nurse + another professional work together
Direct Care
-involves working directly with the patient
Indirect Care
-communicating with other HCPs about care
-delegate, supervise, evaluate others work
-plan and document care
