mod 5 ch 16 Flashcards
nursing process
- Critical thinking
- Patient-centered care
- Goal-oriented tasks
- Evidence-based practice
- Nursing intuition
The nursing process utilizes five sequential steps: assessment, analysis, planning, implementation, and evaluation.
nursing process
- Assessment- gather data, obj and subj
- analysis- cluster data and id problem
- planning- dev plan of care to achieve goals
- implementation- carry out plan
- evaluation- collect to evaluate, revise plan as needed or end if obj reached
effective use nursing process
- It is organized.
- It is outcome-oriented.
- It is collaborative, incorporating an interprofessional team.
- It is dynamic, changing over time in response to patient needs.
- It requires knowledge application, analysis, and critical thinking.
- It is universally adaptable to all types of patients in all kinds of health care settings.
Which nursing skill is essential to utilize throughout the nursing process?
Critical thinking
Critical thinking requires that the nurse think logically about the patient’s health problems and how best to address them, and it is used throughout the nursing process.
Place the steps of the nursing process in the order in which each should occur.
Assessment Analysis Planning Implementation Evaluation
Match the nursing process characteristic to its description.
The nursing process incorporates the interprofessional team.
—Collaborative
Nurses evaluate patient results to determine effectiveness.
—-Outcome-oriented
Nurses use critical thinking for each step of the nursing process.
—–Analytical
The nursing process helps ensure that patient care is well planned.
—–Organized
analysis
recognize cues then form diagnostic conclusions based on identified patters
clinical judgement based on collected data
collaborative problem- actual problem treated by interdisciplinary team
critical thinking
promotes thorough, comprehensive, and accurate analysis to identify nursing diagnoses unique to the individual patient
diagnostic decision-making process
includes clustering data, identifying patient problems, and formulating diagnoses.
International Classification for Nursing Practice (ICNP)
standardized nursing language system used for point-of-care documentation for patient data and clinical activity. ICNP language can be used to identify diagnoses, interventions, and outcomes.
Which nursing concept is defined as an actual or potential problem or response to a problem?
diagnosis
Which aspects do nurses make judgments about when determining initial nursing diagnoses?
- vulnerabilities
- pt problems
- health promotion
- risk for problems
Which action reflects a primary task in the analysis step of the nursing process?
Forming diagnostic conclusions
Nurses form diagnostic conclusions according to identified problems that reflect patient conditions requiring nursing care in the analysis step of the nursing process.
3 types nursing interventions
- nurse-initiated- do not require HCP prescription
- HCP initiated
- collaborative
Which term describes how the nursing process changes over time in response to patients’ individual needs?
dynamic
Which statement defines collaborative interventions?
Involve the expertise of health care team members
Match the type of nursing intervention to the example.
Patient positioning ---Independent Foley catheter insertion ----Dependent Respiratory therapy consult ----Interdependent
giving care
direct care- care on pts
indirect care- performed on behalf of pts
implementing care
- –Reassess the patient.
- —Review and revise the existing plan of care.
- –Organize resources and care delivery.
- —Anticipate and prevent complications.
- –Implement nursing interventions.
Which function describes the primary purpose for documenting nursing interventions?
Facilitate communication.
Communication is the most important reason proper documentation is performed. It facilitates communication among all health care team members and decreases the potential for error
During the implementation step of the nursing process, a nurse reviews and revises a patient’s plan of care. Place the steps of review and revision in the order in which each should occur.
- Reassess the patient.
- Review and revise the existing plan of care.
- Organize resources and care delivery.
- Anticipate and prevent complications.
- Implement nursing interventions.
critical thinking process
- examine results
- compare achieved effect w goals and outcomes
- recognize errors
evaluation
- question interventions
- revise plan
Which aspect would the nurse consider as a component of the evaluation step of the nursing process?
The patient’s achievement of short- and long-term goals
The evaluation phase is specifically when the nurse determines whether the patient’s short- and long-term goals were met.
Which critical-thinking functions must the nurse perform to effectively evaluate patient goals during the final step of the nursing process?
- recognizing errors
- compare achieved effect w goals
- examine results acc to clinical findings
Which questions are critical for the nurse to ask during each step in the nursing process?
- collected data thorough and accurate?
- could interventions affect pt negatively?
- are all underlying factors addressed in plan care?
Which phrase describes the primary purpose of nursing analysis and diagnosis?
communicate pt problems
Which questions would the nurse ask to evaluate the effectiveness of nursing interventions?
- should plan be discontinued
- have new assessment data been id’d should be considered?
- does plan care need be modified in response to pt changes?
Which characteristics of the nursing process allow the nurse to effectively apply critical thinking to patient care?
- organized
- outcome oriented
- allows rn apply knowledge
- rn think analytically
- incorporates interprofessional tm
Which organization defines standards of nursing practice and states that the nursing process forms the foundation for clinical decision making?
american nurses association
Which step of the nursing process does the nurse use when obtaining the following patient information: blood pressure of 180/75, pulse of 90, and a complaint of chest pain?
assessment
Which type of data do the patient’s family members, friends, or other nurses provide?
secondary
Which type of patient assessment takes into account all factors, such as the patient’s physical, psychological, emotional, environmental, cultural, and spiritual health?
holistic
Which nursing action occurs during the analysis step of the nursing process?
cluster pt data to id pt problems
Which phrases describe the role of the International Classification for Nursing Practice (ICNP) in the nursing process?
- prov stand rn language
- id common labels rn diagnoses’
- prov point care doc for clinical activity
During which step of the nursing process would the nurse prioritize nursing diagnoses?
planning
During which step of the nursing process would the nurse establish long-term goals with the patient?
planning
Which part of the nursing process involves the nurse setting short-term goals for the patient?
planning
Which step of the nursing process involves carrying out nursing actions designed to meet a patient’s unique needs?
implementation
Which intervention reflects direct nursing care?
giving injection
Which statements reflect the nurse’s role during the implementation step of the nursing process?
- accountable safe practice
- perform steps intervention accurately
- understand why intervention planned
Which step of the nursing process considers the effectiveness of nursing care?
evaluation
Which step of the nursing process includes a decision point on whether to discontinue, continue, or revise the plan of care?
evaluation
