Nursing Process Flashcards
- is a systematic problem-solving process that guide all nursing actions
NURSING PROCESS
- This is the type of thinking and doing that nurses use in their practice
NURSING PROCESS
- Is a critical thinking that professional nurses use to apply the best available evidence to caregiving and promoting human functions and responses to health and illness
NURSING PROCESS
- The cornerstone of the nursing profession
NURSING PROCESS
- The skill is essential for the clinical application of knowledge and theory in nursing practice
NURSING PROCESS
NURSING PROCESS is synonymous with
problem solving approach
[What and In?] Dorothy Johnson
Introduced three steps of nursing process:
1959
- Assessment
- Decision
- Nursing Action
Lydia Hall
- originated the term “nursing process” in
1955
Lydia Hall
- originated the term “nursing process” in 1955
3 steps:
- Note observation
- Ministration of care
- Validation
[What and In?] Ida Jean Orlando
- identified three steps of nursing process in
1961
- Client’s Behavior
- Nurse’s Reaction
- Nurse’s Action
Yura and Walsh has the 4 components of nursing process:
1961
- Assessing
- Planning
- Implementing
- Evaluating
Knowles
- described nursing process:
1961
- Discover - Do
- Delve - Discriminate
- Decide
What is the Nursing Process?
Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation
the nurse collects patient’s health data
Assessment
a systematic, dynamic process by which the nurse, through interactions with the client, significant others and health care providers, collects and analyzes data about the client
Assessment
gathering information about the client’s status
Data collection
Types of Data
Subjective Data
Objective Data
- Coming from the mouth of patient or significant others
Subjective Data
- Symptoms or covert data
Subjective Data
- Information told to the nurse by the client, family or community
Subjective Data
- Apparent only to the person affected and can be described or verified only by that person
Subjective Data
- Client’s sensations, feelings, values, beliefs, attitudes, perception of personal health status and life situation
Subjective Data
- What health care providers observe
Objective Data
- Signs or overt data
Objective Data
- Information gathered through a physical assessment or from laboratory or diagnostic test
Objective Data
- It can be measured or observed by the nurse or other health care providers
Objective Data
Sources of Data
Primary Data
Secondary Data
- Subjective or objective data obtained from the client; what the client says or what you observe
Primary Data
- All sources other than the client (significant others, client records, health care professionals)
Secondary Data
Methods of Data Collection
Observation
Interview
- Deliberate use of all five senses to gather and interpret patient and environment
Observation
- “All that you can see, hear, feel, smell or sense becomes data in the context of assessment”
Observation
- Planned communication or conversation with a purpose
Interview
- Purposeful structural communication in which you question the patient to gather subjective data for the nursing database
Nursing Interview
- The nurse analyzes the data gathered during assessment and identifies problem areas for the patient. The nurse then makes a diagnosis.
Diagnosis
- Applies to the label when nurses assign meaning to collected data appropriately with NANDA-I-approved nursing diagnosis
Nursing Diagnosis
- Made by the physician or advance healthcare practitioner that deals more with the disease, medical condition or pathological state only a practitioner can treat
Medical Diagnosis
Components of Nursing Diagnosis
- Problem Statement/ Diagnostic Label
- Etiology
- Risk Factors
- Defining Characteristics
- Describe the client’s health problem or response for which nursing therapy is given as concisely as possible
Problem Statement/Diagnostic Label
- Words that have been added to some NANDA
Qualifiers
inadequate, incomplete
Deficient
made worse, damaged
impaired
lesser in size
decreased
not producing the desired effect
ineffective
to make vulnerable to threat
comprised
- Also known as “related factors”
Etiology
- Component of a nursing diagnosis label that identifies one or more probable cases of the health problem
Etiology
- The conditions involved in the development of the problem
Etiology
- Gives direction to the required nursing therapy
Etiology
Etiology is linked to the problem statement with the phrase
“related to”
- Used instead of Etiological factors for risk nursing diagnosis
Risk Factors
are forces that puts an individual or group at an increased vulnerability to an unhealthy condition
Risk Factors
- “As manifested by guarding behavior”
Signs and Symptoms
- “as evidenced by”
- “as manifested by”
Defining Characteristics
- The clusters of signs and symptoms that indicate the presence of a particular diagnostic label
Defining Characteristics
Types of Nursing Diagnosis
- Actual Nursing Diagnosis
- Risk Nursing Diagnosis
- Possible Nursing Diagnosis
- Wellness Diagnosis
- Syndrome Diagnosis
- Is a client problem that is present at the time of the nursing assessment. Their diagnoses are based on the presence of associated signs and symptoms
Actual Nursing Diagnosis
- Refers to the problem that exist at the present moment
Actual Nursing Diagnosis
Formula of Actual Nursing Diagnosis
Patient’s Problem + Etiology + Signs and Symptoms = Actual Nursing Diagnosis
- Are clinical judgment that a problem does not exist, but the presence of risk factors indicates that a problem is likely to develop unless nurses intervene
Risk Nursing Diagnosis
- A clinical judgment that is more vulnerable to develop the problem
Risk Nursing Diagnosis
Formula of Risk Nursing Diagnosis
Problem Statement + Risk Factors = At Risk/High Risk Nursing Diagnoses
- Are statements describing a suspected problem for which additional data are needed to confirm or rule out the suspected problem
Possible Nursing Diagnosis
- The nurse may decide to formulate a tentative or possible nursing diagnosis
Possible Nursing Diagnosis
Wellness Diagnosis is also known as
Health Promotion Diagnosis
- Is a clinical judgment about motivation and desire to increase well-being
Wellness Diagnosis
- Concerned in the individual, family or community transition from a specific level of wellness to a higher level of wellness
Wellness Diagnosis
- Describes human responses to levels of wellness in an individual
Wellness Diagnosis
- Associated with a cluster of other diagnosis
Syndrome Diagnosis
- Written as one-part statement requiring only the diagnostic label
Syndrome Diagnosis
- The nurse identifies expected outcomes individualized to the patient
Outcome Identification
- The nurse analyzes the strengths and weaknesses of the patient, the patient’s family, nursing personnel, the healthcare facility, and the available resources
Outcome Identification
Activities in the Outcome Identification Phase:
Setting Priorities + Establishing Outcomes = Outcome Identification
Formula of Outcome Identification
Follow Maslow’s hierarchy of basic needs to guide the delivery of care
is a measurable, expected, client-focused goal to be achieved at some specified time in the future
Outcome
In establishing outcomes, it must be:
S – specific
M – measurable
A – attainable
R – relevant
T – time bound
E – evaluate
R – reevalute
Components of an outcome identification
Patient behavior + criteria of performance + conditions (if needed) + time frame = Outcome Statement
- Activity is observable that can be seen, heard, felt or measured by the nurse or reported by the patient
Patient Behavior
- Specifies a realistic improvement in functioning in the problem area by a stated time to determine whether the outcome was satisfactorily achieved
Criteria of performance
The level at which the patient will perform the behavior.
Criteria of acceptable behavior
- Outcomes with the patient that require the use or presence of certain environmental conditions
Conditions
- The circumstances under which the behavior will be performed
Conditions
a time or date to clarify to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome
Time frame
- Patient can achieve fairly quickly in a matter of hours, in an 8-hour shift, or on daily basis
a. Intermediate outcomes (short term)
- Gives direction for nursing care over time. If the patient has alterations in some functions, the long-term outcome is to restore a normal pattern of functioning
b. Long term or final outcomes
- The nurse develops a plan of care that prescribes interventions to attain expected outcomes
Planning
Types of Nursing Interventions
Independent
Dependent
Collaborative
- One that nurses are licensed to prescribe or perform based on their knowledge and skills
- Nurses are accountable for their decisions
Independent
- One that is prescribed a physician and carried out by the nurse
Dependent
- An interdependent intervention
- Carried out in collaboration with other health team members (PT, dieticians, physician)
Collaborative
- Nurse implements the interventions identified in the plan of care
Implementation
Implementation Formula:
Validation/validating care plan + documenting care plan
- The nurse evaluates the patient’s progress toward attainment of outcomes
- Result
Evaluation
occurs continuously which care is being given, shift by shift as nurses evaluate progress toward intermediate outcomes and summatively at discharge
Evaluation
4 possible judgments that may be made:
- The goal was completely met
- The goal was partially met
- The goal was completely unmet
- Ongoing
is a systematic problem solving process that guide all nursing actions. This is the type of thinking and doing that nurses use in their practice (ANA, 2004)
Nursing Process
What is distinguished as a separate step of nursing process in 1973
diagnosis
Differentiated as a distinct step of the nursing process
Outcome identification
Focus of interview
establishing rapport
Gather information
there are three steps in the diagnosis step:
- Data analysis
- Problem identification
- Formulation of nursing diagnosis
Two parts of problem statement/diagnostic label
QUALIFIERS AND FOCUS
Enables the nurse to individualized the client’s care
Etiology
A clinical judgment concerning with a cluster of problem or risk nursing diagnosis that are predicted to present because of a certain situation or event
syndrome diagnosis
are those specific activities the nurse plans and implements to help the patient achieve an outcome
nursing interventions
to appraise the extent to which goals and outcome criteria of nursing care have been achieved
Evaluation
four distinct activities in the evaluation phase
documenting responses to interventions + evaluating effectiveness of interventions + evaluating outcome achievement + reviewing nursing care plan = evaluating
is a method for organizing health information in the individual’s record
FDAR Focus charting
It is a systematic approach to documentation, using nursing terminology to describe individual’s, health status and nursing action
Focus charting
keyword or diagnostic category from a nursing diagnosis or collaborative problem on the planof care
focus
An acute change in individuals condition
Focus
A significant event in an individual’s care
focus
A keyword or phrase indicating compliance with a standard of care or agency policy
Focus
subjective or objective information supporting the stated focus or describing observations at the time of significant eventss
data
nursing interventions performed, plan to be performed, and or protocol and procedures initiated
Action
Description of individuals response to medical or nursing care
Response
Statement that the action plan of care outcomes has been attained or are progressing toward attainment
response
