nursing process

Question 1

Define nursing process

Answer 1

the diagnosis and treatment of human responses to actual or potential health problems. (ANA 1980)

Question 2

Who was the first person to introduce the term “nursing process” in 1955?

Answer 2

Lydia Hall

Question 3

Who identified functional health patterns in 1976?

Answer 3

Marjory Gorden

Question 4

Who are the group of people in charge of the terminology used in nursing and when were they established?

Answer 4

NANDA - North American Nursing Diagnosis Association, 1982

Question 5

Who is the leader of NANDA, and what college was she an instructor at?

Answer 5

1989 Lynda Carpenito/ Nursing Dx/ approved by ANA

Question 6

what year did the ANA revise the definition of nursing?

Answer 6

2003

Question 7

When does NANDA refine their nursing diagnosis list?

Answer 7

every two years, biennial

Question 8

The nursing process is a problem solving process for nursing care…

Answer 8

its systematic, dynamic, interactive, flexible, and theoretically based

Question 9

components of the nursing process (5)

Answer 9

assessing, diagnosing, planning, implementing, and evaluating

Question 10

what are the benefits of the nursing process?

Answer 10

patient, nurse, and professional benefits

Question 11

nursing benefits in the nursing process

Answer 11

continuity of care, individualized patient centered care, encourages patient and family participation in care

Question 12

nurse benefits in the nursing process

Answer 12

professional growth, innovated/creative in style of care, and more effective in adm. care/ collaborate with other HCW

Question 13

professional benefits in the nursing process

Answer 13

defines our scope of practice, our role to the consumer, and what we do for other HCP

Question 14

Assessing in the nursing process

Answer 14

collect, organize, validate, and document data. first step in the nursing process, systematic, identifies current/potential problems, holistic approach, and utilize therapeutic comm. techniques

Question 15

Methods of data collection

Answer 15

observation, interview patient and family, physical exam, and review chart

Question 16

Types of data

Answer 16

subjective and objective

Question 17

Sources of data

Answer 17

primary, secondary, HCT, health records, and literature

Question 18

Data validation

Answer 18

ensures accuracy of info., validates data directly with the patient, compares findings with patients’ chart, and utilize references as needed

Question 19

Data interpretation

Answer 19

cues: data acquired through one of five senses (sub. and obj. data) the more cues, more potential
for accurate diagnosis and inferences: always subjective, nurses judgment or interpretation of the cues

Question 20

Diagnosis

Answer 20

second step in the NP. clinical judgment, provide basis for interventions

Question 21

Steps in developing a nursing diagnosis

Answer 21

identify the problem using NANDA list, id etiology, and id the defining characteristics

Question 22

Types of nursing diagnosis

Answer 22

actual, risk, health problems, and syndrome

Question 23

Actual nursing diagnosis

Answer 23

clinically validated (S/S), actual Dx does not appear in ND statement, statement comes from NANDA list whenever possible (3 parts)

Question 24

What are the three parts to the nursing diagnosis?

Answer 24

problem (NANDA label and definition), etiology (related to and risk factors), and defining characteristics (S/S)

Question 25

Risk nursing diagnosis

Answer 25

risk factors that contribute to increased vulnerability, prevent the occurrence (doesn’t have AEOs), written as a 2 part statement (NANDA label/etiology), represent potential not actual problems

Question 26

health promotion diagnosis

Answer 26

1 part statement, patients readiness to enhance specific health behaviors

Question 27

Comparison of medical vs nursing diagnosis

Answer 27

Medical: describes a disease, stays the same as long as disease is present, treatable by physicians. Nursing: describes a human response, changes from day to day, treatable by nurses

Question 28

DOs and DONTs for writing nursing diagnosis

Answer 28

do not include medical DX in the ND statement, use R/T rather than due to/caused by, 2 part statement shouldn’t mean the same, legally advisable terms, and without judgments

Question 29

planning

Answer 29

third step, 3 components: prioritize the ND, develop

goals/ EO, and plan NI

Question 30

Setting priorities

Answer 30

ND are classified as high, intermediate (medium), or low priority

Question 31

High priority

Answer 31

immediate attention life threatening

Question 32

intermediate priority

Answer 32

not life threatening may result in physical or emotional consequence

Question 33

low priority

Answer 33

can be resolved with minimal intervention

Question 34

establishing expected outcomes

Answer 34

focus on observable, measurable changes in a persons health status, descriptive statements about what the patients state will be after the NIs are carries out, developed with the patient, and evaluated daily/modified as needed

Question 35

components of an expected outcome

Answer 35

subject (patient), verb (behavior), qualifier (criteria for behavior), and time frame ( completed by…)

Question 36

Planning nursing interventions

Answer 36

how to assist patient to achieve the EO, direct individualized patient care, based on sound rationale, and prioritized (always assess first)

Question 37

Types of nursing interventions

Answer 37

independent, dependent, and interdependent/collaborative

Question 38

independent NI

Answer 38

no MD order, nurse prescribed (w/in scope of practice), reduce/eliminate the problem, teaching, monitoring/assessing

Question 39

dependent NI

Answer 39

MD order, maintaining diet, activity and rest, adm. meds., adm. IV fluids., providing Tx, scheduling Dx studies, nurse responsibility to check and validate orders!

Question 40

interdependent/collaborative NI

Answer 40

MD and RN prescribed interventions, nurse is responsible for monitoring for possible or actual complications, treating the patient to prevent or manage the complication, actions carried out with HCT

Question 41

Types of independent NI

Answer 41

Cognitive, interpersonal, technical, and monitoring

Question 42

Cognitive NI

Answer 42

teach/educate, relate knowledge to ADLs, positive feedback, and supervised client/family response

Question 43

Interpersonal NI

Answer 43

therapeutic communication, serve as role model, sets limits, opportunity to exam values and attitudes, provide spiritual support, humor, and individual group therapy

Question 44

Technical NI

Answer 44

provides basic hygiene care, routine nursing activities, independent and dependent tx, assist with ADLs, and use of special abilities

Question 45

Monitoring NI

Answer 45

always assessing and re-assessing!!

Question 46

Implementing

Answer 46

fourth step, carrying out plan of care, NIs initiated and completed, and NIs based on sound rationale

Question 47

Process of implementation

Answer 47

reassess the client, determine the nurses need for asst., implement the nursing interventions, encourage active participation of the patient, supervise the delegated care, and document nursing activities

Question 48

Evaluating

Answer 48

fifth step, patients response to the NIs and extent to which the EOs have been achieved, modify the components as needed, and ongoing process