NP Flashcards
is a systematic problem solving process that guide all nursing actions.
Nursing Process
This is the type of thinking and doing that nurses use in their practice (ANA, 2004).
Nursing Process
Organized Systematic
Goal - oriented
Humanistic care
-leads to ?
Effective and Efficient NP
Introduced three steps of nursing process in 1959
Dorothy Johnson
Dorothy Johnson’s 3 Steps in Nursing Process
Assessment
Decision
Nursing action
Originated nursing process in 1955
Lydia Hall
Lyda Hall three steps in Nursing Process
Note Observation
Ministration of care
Validation
Identified three steps of nursing process: 1961
Ida Jean Orlando
Ida Jean Orlando Nursing Process steps
Clients behavior
Nurse’s reaction
Nurse’s actions
has the four components of nursing process: 1967
Yura and Walsh
Yura and Walsh has the four nursing components of nursing process:
Assessing
Planning
Implementing
Evaluating
Described nursing process in 1967
Discover
Delve
Do
Decide
Descriminate
True or False
ANA: Diagnosis distinguished as a separate step of nursing process 1973
True
True or False
ANA :Diagnosis of actual and potential health problems delineated as integral part of nursing practice. 1973
False;1980
• differentiated as a distinct step of the nursing process. (ADOPIE)
Outcome identification
A systematic, dynamic process by which the nurse, through interaction with the client, significant others, and health care providers, collects and analyzes data about the client (ANA, 2004).
Assessment
Data may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle
Assessment
Types of Data
Subjective and Objective Data
- “Symptoms” or covert data
Subjective Data
-Client’s sensation, feelings, values, beliefs, attitudes, perception of personal health status and life situation.
Subjective Data
Information told to the nurse
Subjective Data
- “signs” or Overt data
Objective Data
- Vital signs results, x-ray test results, skin color and urine output.
Objective Data
Information gathered through a physical assessment or from laboratory or diagnostic test.
Objective Data
True or False
Objective Data: It can be measured or Observed by the nurse or other health care providers
What the nurse Observes
True
Gathering information about the client’s status
Data collection
Sources of Data
Primary Data
Secondary Data
Subjective or objective data obtained from the client: what the client says or what you observe.
Primary Data
All sources other than the client
- Significant others
- Client records
- Health care professionals
Secondary Data
Methods of Data Collection
Observation
Interview
-“All that you see,smell or sense becomes data in the context
Observation
• planned communication or a conversation with a purpose.
Interview
True or False
Observation is the Deliberate use of all five senses to gather and interpret patient and environment.
True
• Purposeful, structured communication in which you question the patient to gather subjective data for the nursing databas
Nursing Interview
Focus of Nursing Interview
Focus:
• Establishing rapport
• Gather information
•
• Is the second step of Nursing Process
• The nurse analyzes the assessment data in determining Diagnoses.
DIAGNOSIS
True or False
the nurse analyzes the data gathered during assessment and identifies problem areas for the patient.
The nurse then makes a nursing diagnosis.
True
applies to the label when nurses assign meaning to collected data appropriately labeled with NANDA-I-approved nursing diagnosis
Nursing diagnosis
is made by the physician or advance health care practitioner that deals more with the disease, medical condition, or pathological state only a practitioner can treat.
Medical Diagnosis
There are three steps in the diagnosis step:
Data Analysis
Problem identification
Formulation of Nursing Diagnosis
COMPONENTS OF A NURSING DIAGNOSIS
Problem statement/Diagnostic label
Etiology
Risk Factors
Defining Characteristics
describes the client’s health problem or response for which nursing therapy is given as concisely as possible.
Problem statement/Diagnostic label
Problem Statement/Diagnostic Label two parts
two parts: QUALIFIER & FOCUS (of the diagnosis)
:
-are words that have been added to some NANDA label to give additional meaning to the diagnostic statement:
QUALIFIERS
Deficient -
Impaired-
Decreased -
Ineffective -
Compromised -
Deficient - (inadequate in amount, quality, or degree; not sufficient; incomplete)
Impaired - (made worse, weakened, damaged, reduced, deteriorated)
Decreased - (lesser in size, amount, or degree)
Ineffective - (not producing the desired effect)
Compromised - (to make vulnerable to threat).
- Also known as “related factors”
- component of a nursing diagnosis label that identifies one or more probable causes of the health problem,
Etiology
- are used instead of etiological factors for risk nursing diagnosis.
Risk Factors
- are forces that puts an individual (or group) at an increased vulnerability to an unhealthy condition.
Risk factors
- the conditions involved in the development of the problem
- gives direction to the required nursing therapy
- enables the nurse to individualize the client’s care.
Etiology
True or False
Etiology is linked with the problem statement with the phrase “related to”.
True
- the clusters of signs and symptoms that indicate the presence of a particular diagnostic label.
Defining Characteristics
True or False Defining characteristics are written following the phrase
“as evidenced by” or “as manifested by” in the diagnostic statement.
True
the defining characteristics are the identified signs and symptoms of the client.
Actual Nursing Diagnosis
no signs and symptoms are present therefore the factors that cause the client to be more susceptible to the problem form the etiology of a risk nursing diagnosis.
For risk nursing diagnosis
TYPES OF NURSING DIAGNOSIS
ACTUAL NURSING DIAGNOSIS
RISK NURSING DIAGNOSIS
POSSIBLE NURSING DIAGNOSIS
WELLNESS DIAGNOSIS
SYNDROME DIAGNOSIS
- is a client problem that is present at the time of the nursing assessment. These diagnoses are based on the presence of associated signs and symptoms.
ACTUAL NURSING DIAGNOSIS
refers to the problem that”exist at the present moment.’
Actual Nursing Diagnosis
Actual Nursing Diagnosis Formula
Patient’s Problem + Causes if Known = Actual Nursing Diagnosis
- These are 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
FORMULATING A RISK NURSING DIAGNOSIS
Problem Statement + Risk Factors = At Risk/High Risk Nursing Diagnoses
- a clinical judgment that is more vulnerable to develop the problem.
Risk Reduction Diagnosis
- Possible nursing diagnoses are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem.
POSSIBLE NURSING DIAGNOSIS
- the nurse may decide to formulate a tentative or possible nursing Diagnosis
Possible Nursing Diagnosis
Possible Nursing Diagnosis
Possible+Diagnostic Label
- Also known as Health promotion diagnosis
- is a clinical judgment about motivation and desire to increase well-being.
Wellness Diagnosis
True or False
Components of a health promotion diagnosis generally include only the diagnostic label or a one-part-statement. It may also include a defining characteristic.
True
Wellness Diagnosis Formula
Health Promotion Label + defining Characteristics
Data may include the following dimensions:
physical,
psychological,
sociocultural,
spiritual,
cognitive,
functional abilities,
developmental,
economic,
and lifestyle
