Nursing Process

Question 1

What is the nursing process

Answer 1

Framework to identify diagnose and treat human responses to health and illness
Requires critical thinking
ADPIE

Question 2

What is ADPIE

Answer 2

Assessing
diagnosing
planning
implementing
evaluating

Question 3

What are the characteristics of the nursing process

Answer 3

Analytical, Dynamic, Organized, Outcome oriented, Collaborative, Adaptable

Question 4

What does it mean to be adaptable

Answer 4

To be able to adjust according to what’s wrong with the patient, constantly prioritizing

Question 5

What are the steps to the nursing process and brief decription

Answer 5

Assessment: data is gathered through observations
Diagnosis: Data is analyzed, validated and clustered. problem is then stated in the diagnosis’ provided
Planning: Diagnoses are prioritized and goals are identified
Implementation: Interventions are set and treatments designed to achieve goals and outcomes
Evaluation: Nurse determines: were goals met? What was effective? What wasn’t?

Question 6

What is critical thinking

Answer 6

Using thinking to provide clarity and increase precisions to specific situations
Allows nurses to collect essential patient data

Question 7

Care plans

Answer 7

Developed using the nursing process
Handwritten or part of EMR
All patients have their own unique, patient centered plans designed to meet their specific needs

Question 8

Assessment

Answer 8

Data collection begins at the first direct or indirect encounter with the patient
Collected through patient interview, health history, physical assessment
Collected from variety of sources, family, friends, records, labs
Data is organized, validated and established un database

Question 9

Direct encounter

Answer 9

Nurse controlled, very structured, to obtain specific info

Question 10

Indirect encounter

Answer 10

Patient controlled, helps build rapport

Question 11

What is primary data

Answer 11

Information obtained directly from a patient

Question 12

What is Secondary data

Answer 12

Collected from family members, friends, health care professionals. or medical records and tests

Question 13

What is subjective data

Answer 13

Spoken data ( symptoms )
Patients feeling about a situation or comments about how they are feeling
Documented in the patients medical records as quotations “I didn’t get much sleep”

Question 14

What is objective data

Answer 14

Observable or measurable
Data collected from medical records, laboratory, diagnostic test results
( pale skin, vomited 50 mL )

Question 15

Diagnosis

Answer 15

Identifies a problem, potential problem, or opportunity of improvement
3 types: Actual, Risk and Health promotion

Question 16

What is a risk nursing diagnosis

Answer 16

Where a problem does not exist but there are risk factors indicating it’s likely to develop unless intervened

Question 17

What is a health promotion diagnosis`

Answer 17

Reflects the patient’s readiness to improve an aspect of health, awareness of well-being and the desire to maintain or enhance this state

Question 18

What is actual diagnosis

Answer 18

Patient problem that is PRESENT at the time of the nursing assessment

Question 19

Planning

Answer 19

Prioritizes nursing diagnosis, establishes short and long term goals
Chooses outcome indicators,
Identifies interventions to address specific goals

Question 20

How do you prioritize diagnosis

Answer 20

Priority goes to the most severe
severity depends on symptoms and the patients preference

Question 21

What are short term goals

Answer 21

Extend less then 1 week

Question 22

What are long term goals

Answer 22

Last weeks to months

Question 23

Implementation

Answer 23

Focuses on the initiation of appropriate interventions designed to meet needs of patient
Interventions can be dependent, independent or collaborative
Care can be direct or indirect
3 types of clinical plans

Question 24

Direct care

Answer 24

Interventions that are carried out by having personal contact with the patient
Cleaning incision, administering injection

Question 25

Indirect care

Answer 25

Interventions performed to benefit patients but do not involve face to face
giving change of shift report, communicating with other team members

Question 26

Dependent interventions

Answer 26

Tasks the nurse undertakes that are within nursing scope of practice but require the order of a primary care provider
( administering oxygen or meds )

Question 27

Clinical pathway care plan

Answer 27

Care pathway, maps or critical pathways.
Multidisciplinary resources that guide patient care

Question 28

Protocol care plan

Answer 28

Written plans that can be generalized to groups of patients with same or similar needs

Question 29

Standing order care plan

Answer 29

Physician orders that are pre-approved

Question 30

Evaluation

Answer 30

Focuses on the patients response to the nursing interventions and goals
Identifies the effectiveness of interventions
Determines if the short and long term goals were met and if desired outcomes were achieved