Nursing Process

Question 1

Skills necessary to perform the nursing process?

Answer 1

• Critical thinking, clinical reasoning, communication, concept-based learning

Question 2

6 phases of the nursing process

Answer 2

Assessment, Diagnosis, outcome, planning, implementation, evaluation

Question 3

Assessment:

Answer 3

• Collection of subjective and objective data
• Holistic
• Info gathered about past and present (primary, secondary)

Question 4

Where does the data come from?

Answer 4

-Lab data, diagnostic test, physical examination, health records

Question 5

Subjective vs. Objective Data

Answer 5

• 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

Question 6

Method to obtain subjective data

Answer 6

Interview

Question 7

Method to obtain objective data

Answer 7

Inspection, palpation, percussion, auscultation, measurement devices, health record, lab studies, diagnostic procedures

Question 8

Admission Assessment

Answer 8

Initial identification of normal fxn, fxn status, collection of data for baseline comparison

Question 9

Admission assessment timeframe

Answer 9

• after admission to the hospital,SNF, ambulatory healthcare center, or home healthcare
• 8-12 pages, 30 mins, head to toe

Question 10

Focus Assessment

Answer 10

-Status determination of a specific problem identified during previous assessment

Question 11

Focus Timeframe

Answer 11

• Ongoing process; integrated with nursing care; a few mins to a few hours btwn assessments

Question 12

Time-lapse reassessment

Answer 12

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.

Question 13

Time-lapse timeframe

Answer 13

Several months (3,6,9 mo or more) btwn assessments 
-primary care f/u

Question 14

Emergency Assessment

Answer 14

Identification of life-threatening situation

Question 15

Emergency timeframe

Answer 15

Any time a physiological, psychological, or emotional crisis occurs

Question 16

clinical skills used in assessment?

Answer 16

Observation, Interviewing, Physical examination

Question 17

Observation

Answer 17

The act of noticing patient cues

Question 18

Interviewing

Answer 18

Interaction and communication process for gathering data by questioning and information exchange

Question 19

Physical Examination

Answer 19

Analysis of bodily fxn, using the techniques of inspection, palpation , percussion, and auscultation

Question 20

Phases of the Interviewing?

Answer 20

• 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

Question 21

Four steps of Physical Assessment

Answer 21

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

Question 22

Diagnosis

Answer 22

• 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

Question 23

What are the components of a Nursing Diagnosis?

Answer 23

• 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

Question 24

PES Format

Answer 24

P: problem (diagnostic label)
E: etiology (related factors)
S: Signs/ symptoms (defining characteristics)

Question 25

Outcomes need to be

Answer 25

-Measurable, realistic, patient-focused

Question 26

Planning is the…

Answer 26

development of a care plan to address the outcomes

Question 27

Outcome Identification involves prioritization

Answer 27

• Determine priority by urgency or importance

- Life-threatening takes priority for sure

Question 28

What takes priority after life threatening

Answer 28

• Mid level, low level, pain,

Question 29

What is a nursing intervention

Answer 29

• Any treatment based upon clinical judgement and knowledge that a nurse performs to enhance patient outcomes
• psychomotor, psychosocial, educational, maintenance, surveillance, supervisory, sociocultural

Question 30

Types of Cognitive Nursing interventions

Answer 30

• Teach/educate, relate knowledge to ADLs, provide feedback, delgate to UAP, supervise nursing team,

Question 31

Types of interpersonal interventions

Answer 31

-coordinate activities, provide caregiving, provide a personal presence, explore and legitimize feelings, provide spiritual support, use humor, serve as a role model.

Question 32

Types of Technical intervention

Answer 32

• provide basic skin care and hygiene
• perform routine nursing activities
• detect changes in baseline data
• Assist with ADLs

Question 33

General format for care plans?

Answer 33

Nursing diagnostic statement ( patient problem)

• patient goals
• nursing interventions
• evaluation

Question 34

Implementation

Answer 34

• 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

Question 35

Delegation

Answer 35

• 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

Question 36

Principles of delegation

Answer 36

• 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

Question 37

What cannot be delegated?

Answer 37

Assessment, pt teaching, tasks that involve clinical judgement, evaluation

Question 38

Evaluation

Answer 38

• 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.