Nursing Process Flashcards
North American Nursing Diagnosis Association (NANDA)
1982
Lydia hall introduced the term “nursing process”
1955
What are the components of the nursing process?
Assessing Diagnosing Planning Implementing Evaluating AD-PIE
Promotes continuity of care; patient centered care; individualized; participation of the family and patient.
Patient benefits
Improves professional growth; allows nurse to be innovative and creative; more effective care, allows collaboration with other team members.
Nurse benefits
Defines our scope of practice; defines our role to the consumer; defines what we do; it’s a basic standard with joint commission.
Profession benefits
1st step: deliberate systematic collection of data, holistic approach; utilizes therapeutic communication
Assessing
Covert
Patients perception
Overt
Observations or measurements
Ensures accuracy of information
Data validation
Cues and interpretation
Data interpretation
Data acquired through one of the 5 senses including subjective and objective data
Cues
Nurses judgement or interpretation of cues; always subjective
Inferences
2nd step: nanda
Diagnosis
Physiological problems that nurses monitor and collaborate with medicine for co-treatment
Collaborative problems
3rd step: 3 components; prioritize the nursing diagnosis, develop patient goals, plan nursing interventions
Planning
Components of an an expected outcome: SVQT
Subject
Verb
Qualifier
Time frame
Nurse prescribed
Independent
Physician prescribed
Dependent
Physicians and nurses
Collaborative
What are the 4 types of
Independent nursing interventions
Cognitive
Interpersonal
Technical
Monitoring
Teach/educate, related to knowledge to ADLs, supervise family performance, improve feedback
Cognitive
Use therapeutic communication, set limits, provide opportunity to examine values and attitudes, provide spiritual support
Interpersonal
Provides basic hygiene, perform routine nursing, activities, provides independent and dependent treatment assist with ADLs
Technical
Ongoing assessment
Monitoring
4th step: carrying out the proposed plan of care to resolve the problem; NIs are based on sound rationale
Implementing
5th step: determine the patients response to NIs and the extent which the EOs have been achieved
Evaluating
What is included in patient preparation?
Patient scheduling Patient teaching Informed consent Physical preparation Collection of supplies
What are the responsibilities of the nurse during testing?
Patient assessment
Patient support
Patient positioning
What are the responsibilities after testing
Patient assessment Specimen collection Documentation Patient and family support Individualized care based on data
What is the purpose of patient teaching?
Promote health
Prevent illness/injury
Restore health
Adapt to altered health
What is the teaching process?
Collect data Determine learning need Prepare teaching plan Implement teaching strategies Evaluate learning CD-PIE
Requirement or desire to know information
Learning need
Desire to learn or act on the learning
Compliance
Commitment to new knowledge/integrate into lifestyle
Adherence
Teaching adults/learn based on need to know
Andragogy
Teaching children
Pedagogy
Teaching older adults/takes longer to process information
Geragogy
Manipulate environment for intended purpose; stimulus Pavlovs Dog
Behaviorism
Learning is a complex thinking process
Cognitivism
Learning occurs in all 3 domains
Cognitive
Affective
Psychomotor
Thinking or intellectual level
Cognitive
Feelings or emotional level
Affective
Skill or motor level
Psychomotor
Teaches from simple to complex; refers to rational thought; the best way to learn is through written test
Cognitive
The hardest domain to teach in; difficult to measure learning in this domain
Affective
Needs to be hands on and demonstrate back
Psychomotor
Learning is self motivated, self initiated, and self evaluated; nursing uses this
Humanism
1 in 5 people read at a 5th grade level or below
Literacy level
8 out of 10 users have searched for health information online
Internet access to healthcare
Individual
Psychomotor
Small group
Cognitive and effective