Nursing Process Flashcards
Skills necessary to perform the nursing process?
- Critical thinking, clinical reasoning, communication, concept-based learning
6 phases of the nursing process
Assessment, Diagnosis, outcome, planning, implementation, evaluation
Assessment:
- Collection of subjective and objective data
- Holistic
- Info gathered about past and present (primary, secondary)
Where does the data come from?
-Lab data, diagnostic test, physical examination, health records
Subjective vs. Objective Data
- Subjective: symptoms, values, perceptions, feelings, attitudes, sensations, beliefs
- Objective: Physical examination, bp, hr, skin color and temp, heart sounds, written reports on healthcare record, lab values
Method to obtain subjective data
Interview
Method to obtain objective data
Inspection, palpation, percussion, auscultation, measurement devices, health record, lab studies, diagnostic procedures
Admission Assessment
Initial identification of normal fxn, fxn status, collection of data for baseline comparison
Admission assessment timeframe
- after admission to the hospital,SNF, ambulatory healthcare center, or home healthcare
- 8-12 pages, 30 mins, head to toe
Focus Assessment
-Status determination of a specific problem identified during previous assessment
Focus Timeframe
- Ongoing process; integrated with nursing care; a few mins to a few hours btwn assessments
Time-lapse reassessment
Comparison of patient’s current status to baseline obtained previously; detection of changes in all fxn areas after an extended period of time has passed.
Time-lapse timeframe
Several months (3,6,9 mo or more) btwn assessments -primary care f/u
Emergency Assessment
Identification of life-threatening situation
Emergency timeframe
Any time a physiological, psychological, or emotional crisis occurs
clinical skills used in assessment?
Observation, Interviewing, Physical examination
Observation
The act of noticing patient cues
Interviewing
Interaction and communication process for gathering data by questioning and information exchange
Physical Examination
Analysis of bodily fxn, using the techniques of inspection, palpation , percussion, and auscultation
Phases of the Interviewing?
- Preparatory phase: Gather all pertinent information, determine what information you want, set the environment
- Introductory phase: Identify who you are, what you are doing, how long you are doing it. DO THIS EVRYTIME YOU ENTER A ROOM!
- Maintenance Phase: Stay focused on the task, facilitate dialogue, answer questions, evaluate when its appropriate to move to next topic
-Concluding Phase: Review goal or task attainment,
summarize highlights, encourage questions
-Make sure they have everything before they leave
Four steps of Physical Assessment
Inspection: visual assessment
Palpation: Use of touch to determine size, shape, and configuration of undying body structures
Percussion: Use of sound from tapping areas on the body to determine underlying body structures
Auscultation: Using a stethoscope to amplify sounds
Diagnosis
- Human responses to actual or potential healthcare problems
- Derived from assessment data
- North American Nursing Diagnosis Association (NANDA)
- Nursing diagnosis is not same as medical
What are the components of a Nursing Diagnosis?
- Diagnostic Label: deficient knowledge, impaired urinary elimination, risk for infection
- Related factors: medical conditions or circumstances that relate to the problem but do not directly cause
- Defining characteristics: observable cues that support it
- Risk Factors: used in risk for diagnoses only elements that “could” cause the problem
PES Format
P: problem (diagnostic label)
E: etiology (related factors)
S: Signs/ symptoms (defining characteristics)
Outcomes need to be
-Measurable, realistic, patient-focused
Planning is the…
development of a care plan to address the outcomes
Outcome Identification involves prioritization
- Determine priority by urgency or importance
- Life-threatening takes priority for sure
What takes priority after life threatening
- Mid level, low level, pain,
What is a nursing intervention
- Any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes
- psychomotor, psychosocial, educational, maintenance, surveillance, supervisory, sociocultural
Types of Cognitive Nursing interventions
- Teach/educate, relate knowledge to ADLs, provide feedback, delgate to UAP, supervise nursing team,
Types of interpersonal interventions
-coordinate activities, provide caregiving, provide a personal presence, explore and legitimize feelings, provide spiritual support, use humor, serve as a role model.
Types of Technical intervention
- provide basic skin care and hygiene
- perform routine nursing activities
- detect changes in baseline data
- Assist with ADLs
General format for care plans?
Nursing diagnostic statement ( patient problem)
- patient goals
- nursing interventions
- evaluation
Implementation
- Focuses on what the nurse will do
- initiation of the plan
- evaluation of the response
- Reassessment
- Recording of actions taken? In the chart or care plan
-interventions evolve as needed during this process
Delegation
- Transfer of responsibility for the performance of a task to another individual while retaining accountability for the outcome
- The nurse is at fault if task is not completed by the delegated person
Principles of delegation
- Right person: trained to perform, willing, and legally able
- Right task: set procedure, familiar to person delgated to, involve minimal risk
- Right circumstance: patient must be stable, able to supervise person performing
- Right communication: communicate what needs to be done and what is expected
- Right evaluation: check if the task was performed
What cannot be delegated?
Assessment, pt teaching, tasks that involve clinical judgement, evaluation
Evaluation
- Was the plan of care successful in addressing the problem
- What do you compare to determine if the plan is successful?
- Assessment data form before and after
- If a plan is unsuccessful then alter interventions, implement new ones, re-evaluate.
