nursing process Flashcards
Define nursing process
the diagnosis and treatment of human responses to actual or potential health problems. (ANA 1980)
Who was the first person to introduce the term “nursing process” in 1955?
Lydia Hall
Who identified functional health patterns in 1976?
Marjory Gorden
Who are the group of people in charge of the terminology used in nursing and when were they established?
NANDA - North American Nursing Diagnosis Association, 1982
Who is the leader of NANDA, and what college was she an instructor at?
1989 Lynda Carpenito/ Nursing Dx/ approved by ANA
what year did the ANA revise the definition of nursing?
2003
When does NANDA refine their nursing diagnosis list?
every two years, biennial
The nursing process is a problem solving process for nursing care…
its systematic, dynamic, interactive, flexible, and theoretically based
components of the nursing process (5)
assessing, diagnosing, planning, implementing, and evaluating
what are the benefits of the nursing process?
patient, nurse, and professional benefits
nursing benefits in the nursing process
continuity of care, individualized patient centered care, encourages patient and family participation in care
nurse benefits in the nursing process
professional growth, innovated/creative in style of care, and more effective in adm. care/ collaborate with other HCW
professional benefits in the nursing process
defines our scope of practice, our role to the consumer, and what we do for other HCP
Assessing in the nursing process
collect, organize, validate, and document data. first step in the nursing process, systematic, identifies current/potential problems, holistic approach, and utilize therapeutic comm. techniques
Methods of data collection
observation, interview patient and family, physical exam, and review chart
Types of data
subjective and objective
Sources of data
primary, secondary, HCT, health records, and literature
Data validation
ensures accuracy of info., validates data directly with the patient, compares findings with patients’ chart, and utilize references as needed
Data interpretation
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
Diagnosis
second step in the NP. clinical judgment, provide basis for interventions
Steps in developing a nursing diagnosis
identify the problem using NANDA list, id etiology, and id the defining characteristics
Types of nursing diagnosis
actual, risk, health problems, and syndrome
Actual nursing diagnosis
clinically validated (S/S), actual Dx does not appear in ND statement, statement comes from NANDA list whenever possible (3 parts)
What are the three parts to the nursing diagnosis?
problem (NANDA label and definition), etiology (related to and risk factors), and defining characteristics (S/S)
Risk nursing diagnosis
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
health promotion diagnosis
1 part statement, patients readiness to enhance specific health behaviors
Comparison of medical vs nursing diagnosis
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
DOs and DONTs for writing nursing diagnosis
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
planning
third step, 3 components: prioritize the ND, develop
goals/ EO, and plan NI
Setting priorities
ND are classified as high, intermediate (medium), or low priority
High priority
immediate attention life threatening
intermediate priority
not life threatening may result in physical or emotional consequence
low priority
can be resolved with minimal intervention
establishing expected outcomes
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
components of an expected outcome
subject (patient), verb (behavior), qualifier (criteria for behavior), and time frame ( completed by…)
Planning nursing interventions
how to assist patient to achieve the EO, direct individualized patient care, based on sound rationale, and prioritized (always assess first)
Types of nursing interventions
independent, dependent, and interdependent/collaborative
independent NI
no MD order, nurse prescribed (w/in scope of practice), reduce/eliminate the problem, teaching, monitoring/assessing
dependent NI
MD order, maintaining diet, activity and rest, adm. meds., adm. IV fluids., providing Tx, scheduling Dx studies, nurse responsibility to check and validate orders!
interdependent/collaborative NI
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
Types of independent NI
Cognitive, interpersonal, technical, and monitoring
Cognitive NI
teach/educate, relate knowledge to ADLs, positive feedback, and supervised client/family response
Interpersonal NI
therapeutic communication, serve as role model, sets limits, opportunity to exam values and attitudes, provide spiritual support, humor, and individual group therapy
Technical NI
provides basic hygiene care, routine nursing activities, independent and dependent tx, assist with ADLs, and use of special abilities
Monitoring NI
always assessing and re-assessing!!
Implementing
fourth step, carrying out plan of care, NIs initiated and completed, and NIs based on sound rationale
Process of implementation
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
Evaluating
fifth step, patients response to the NIs and extent to which the EOs have been achieved, modify the components as needed, and ongoing process
