Nursing Process Flashcards
Steps of the nursing process
Assessing
Diagnosing
Planning
Implementing
Evaluating
What is assessing?
Collecting, validating, and communicating patient data
What is diagnosing?
Analyzing patient data to identify patient strengths and problems
What is planning?
Specifying patient outcomes and related nursing interventions
Establish priorities
We figure out our goals and come up with a plan to meet those goals!
What is implementing?
Carrying out the care plan
What is evaluating?
Measuring the extent to which patient achieved outcomes
Monitor the plan of care, if indicated
What is an initial assessment?
Establish a complete database and provides reference base for problem identification, and future comparison
Done when new patient comes in and at shift change
What is a problem focused assessment?
Ongoing process to determine the status of a specific problem identified in an earlier assessment
Short focused prioritized assessment
What are emergency assessments
Occurs during physiological or psychological crisis to identify life-threatening problems and identify new or overlooked problems
What are time lapsed assessments?
Occurs weeks to months after the initial assessment and compares current status to baseline to reassess health status
Where do we get patient data?
From the patient
Caregiver
Medical record
What are the two types of data?
Objective and subjective
What is subjective data?
Information perceived by the affected person
What is objective data?
Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
What type of data would you validate?
Any type of information that doesn’t make sense
SpO2 is 80% yet patient is breathing perfectly
What is an appropriate nursing diagnosis
It should have 3 parts:
1) diagnosis/problem
2) related to (etiology/cause)
3) as evidenced by (which data supports the diagnosis?)
What is an example of a nursing diagnosis
Patient has fluid volume deficit caused by nausea/vomiting/diarrhea as evidenced by 3 liquid stools in 24 hours, 250 ml of green emesis, dry mucous membranes
What is a risk diagnosis?
There are no related factors (etiology factors) since we are identifying a vulnerability in a patient for a POTENTIAL problem.
The problem is not yet present
What is an example for risk diagnosis
Risk for infection as evidenced by inadequate vaccination and immunosuppression
What is the purpose of the planning step?
Design a plan of care with, and for the patient that results in prevention, reduction, or resolution of the health problem and attainment of the patient’s health expectations
What is the method for the planning step?
Develop goals and outcomes, then design interventions to accomplish them
What are some examples of setting priorities?
Which problems require my immediate attention or that of the team?
Which problems are my responsibility, and which should I refer to someone else?
Which problems are most important to the patient?
What is the difference between goals and nursing interventions?
Goals: are what you want the patient to do or accomplish- not what you are going to do!
Interventions must relate to the goals you set, which must relate to the problems you diagnosed
To be measurable, outcomes should have the following:
Subject- the patient or some part of the patient
Verb- the action the patient will perform
Conditions
Performance criteria- the expected patient behavior or other manifestation in observable, measurable terms
Target time- when the patient is expected to be able to achieve the outcome
An example of a measurable outcome
During the next 24 hour period, the patients fluid intake will total at least 2000 ml
Difference between direct interventions and indirect interventions
Direct: require patient contact
Indirect: actions taken away from the bedside but meant to support the patient goals like talking to a respiratory therapist
What are the 3 main types of interventions?
Independent
Dependent
Collaborative
What is independent intervention?
Nurse initiated interventions
No MD order required
Basic nursing care
What are dependent interventions?
Physician initiated interventions
Requires MD orders
What are collaborative interventions?
Coordination of multiple professionals
What is a good way to approach the intervention step?
What are we going to:
Do, asses, teach, evaluate
Why is the evaluation step a form of assessment?
Because you are assessing how well your patients have met their goals
If they aren’t meeting their goals, you are assessing why
