NURSING PROCESS Flashcards
deliberative, systematic phase of the
nursing process that involves decision
making and problem solving.
planning
Refers to the client’s assessment data and
diagnostic statements for direction in
formulating client goals and designing the
nursing interventions required to present,
reduce or eliminate the client’s health
problems ; nurse’s responsibility
begins with the first client contact
and continuous until Nurse-Client
relationship ends, usually, when the client is
discharged from the health agency
planning
The nurse performs the admission
assessment usually develops the initial
comprehensive plan of care.
initial planning
The nurse has the benefit of seeing the client’s
body language and can gather intuitive kinds
of information that are not available solely
from the
written database
• Occurs at the beginning of a shift as the
nurse plans the care to be given that day
• All nurses who work with the client do
ongoing planning.
ongoing planning
→ To determine whether the client’s health
status has changed
→ To set priorities for the client’s care during
the shift
→ To decide which problems to focus on
during the shift
→ To coordinate the nurse’s activities so that
more than one problem can be addressed
at each client contact
purposes of ongoing planning
process of anticipating and planning
for needs after discharge, is crucial part of
a comprehensive health care plan and
should be addressed in each client’s care
plan ; begins at first client contact
discharge planning
process of establishing
a preferential sequencing for addressing
nursing diagnosis and intervention
setting priorities
In Maslow’s Hierarchy of Needs,
the physiologic needs of a person such
as air, food, and water, are basic needs
to life and receive _ priority
highest
what are the factors to consider when assigning priorities
client’s health values and beliefs
client’s priorities
resources available to the nurse and client
urgency of the health problem
medical treatment plan
Is a desired outcome or change in client
behavior
goal
More specific, measurable criteria used to
evaluate whether goal has been met
expected outcome
a comprehensive taxonomy of patient
outcomes influenced by nursing care.
nursing outcomes classification (NOC)
is required in all phases of the Nursing
Process.
standardized or common nursing language
Goals that can happen quickly
short term goals
Goals that take a long time to achieve
long term goals
Goals and outcomes are derived from the
client’s nursing diagnoses – primarily formt
he ; contains the unhealthy response, what should change
diagnostic label
is the client, any
part of the client, or some attribute of
the client, such as the client’s pulse or
urinary output
subject
specifies an action the client is
to perform
verb
may be added to
the verb to explain the circumstances under
which the behavior is to be performed ; what, where, when, or how
condition or modifier
indicates the standard by
which a performance is evaluated or the
level at which the client will perform the
specified behavior ; speed, accuracy, distance, quality
criterion of desired performance
The establish a time-achievement criterion,
the nurse needs to ask
how long
To establish accuracy criterion, the nurse
asks
how well
Write goals and outcomes in terms of __ not nurse activitie
client responses
Make sure that each goal is derived from
only __ nursing diagnosis.
one
Nursing process is action oriented, client
centered and outcome directed ; action phase in which
the nurse performs the nursing intervention ; doing and documenting
implementation
Treatments performed through interaction
with patients ; medication, IV insertion, counseling
direct care
performed away from the
patient but on behalf of the patient or
group of patients ; managing environment, documentation, interdisciplinary collaboration
indirect care
Nurse initiated intervention ; without supervision or directions from the others ; licensed to initiate on the basis of their knowledge and skills
independent nursing intervention
Health care provider-initiated intervention ; orders or supervision of a licensed pysicians
dependent intervention
• Interdependent intervention
• Are therapies that require the combined
knowledge, skill & expertise of multiple
health care providers
• Actions the nurse carries out in
collaboration with other health team
members
collaborative intervention
safe and appropriate for age, health condition ; achievable w resources available ; congruent w client’s beliefs and other therepies ; based on nursing knowledge and experience; established standards
criteria for choosing nursing intervention
• Problem Solving
• Decision Making
• Critical thinking
cognitive skills
• Verbal non verbal communication
• Therapeutic communication
interpersonal skills
• Manipulating equipment
• Giving injections
• Bandaging
• Moving, lifting and repositioning the client
technical skills
what is the implementation process
reassing a patient
determining the nurse’s need for assistance
implementing nursing intervnetion
supervising the delegated care
documenting nursing activities
→ Continuous process with each patient
interaction modification of a care plan
to meet a client whose status has
changed significantly
→ The nurse must reassess the client to
make sure if intervention is still needed
→ New data may indicate a need to
change the priorities of care of the
reassessing the client
→ The nurse unable to implement the nsg
activity safely or deficiently alone (e.g.
ambulating an unsteady obese client)
→ assistance would reduce stress on the
client (e.g. turning a person who
experience acute pain when moved)
→ The nurse lack of knowledge or skills in
implementing a particular nursing
activities (e.g. nurse
determining the nurses need for assistance
→ Base nursing interventions on scientific
knowledge, nursing research &
professional standards of care
→ Clearly understand the intervention to
be implemented & question any that
are not understood
→ Adapt activities to the individual client
implementing nursing interventions
→ The nurse responsible for the overall
care must ensure that the activities have
been implemented according to the
care plan
→ The nurse validate & responds to any
adverse findings or client response, this
may involve modifying nursing care
supervising delegated care
→ the nurse completes the implementing
phase by recording the interventions &
client responses in the nursing progress
notes
→ Nursing care must not be recorded in
advance
→ The nurse may record routine or
recurring activities ( eg mouth care) in
the client record at the end of the shift
documenting nursing activities
planned, ongoing, purposeful activity
in which the clients & health care
professionals determine:
→ the clients progress towards
achievement of goals/outcomes
→ The effectiveness of the nursing care
plan
evaluation
The desired outcomes must be stated
concretely in _- terms
behavioral
→ During assessment the nurse collects data
for the purposes of __
making diagnosis
→ During evaluation the nurse collects data
for purposes of __
comparing it to preselected
goals/outcomes & judging the effectiveness
of the nursing care
what are the components of the evaluation phase
collecting data
comparing data w desired outcomes
relating nursing acts
drawing conclusions ab problem stat
continuing, modifying, or terminating the nursing care plan
The nurse collects data so that conclusions
can be drawn about whether
goals have been met
• Data must be recorded _ and _ to facilitate the next part of
evaluating process
concisely &
accurately
the client
response is the same as the desired
outcome
goal was met
either a
short term outcome was achieved but the
long term goal was not, or desired goal
was incompletely attained
goal was partially met
TRUE OR FALSE
It should never be assumed that a nursing
activity was the cause of or the only factor
in meeting, partially meeting, or not
meeting a goal
TRUE
The actual problem stated in the nursing
diagnosis has been resolved or the
potential problem is being prevented &
risk factors no longer exist
drawing conclusions
• The potential problem stated in the nursing
diagnosis is being prevented but the risk
factors are still present
drawing conclusions
• The actual problem still exist even though
some goals are being met
drawing conclusions
incomplete or incorrect database ; the nurse needs to
reassess the client and record new data (new data may indicate the need for
new nursing diagnosis, new goals, nursing
intervention)
If the database is incomplete new
diagnostic statements may be required
• If the database is complete the nurse needs
to analyze whether the problems were
identified correctly & whether the nursing
diagnoses were relevant to the database
planning
• If the nursing diagnosis was inaccurate,
obviously the goal/outcome statement will
need revision
• If the nursing diagnosis was appropriate
the nurse then checks if the goals were
realistic & attainable
desired outcomes
Even all the sections of care plan appear
to be satisfactory, the manner in which the
plan was implemented may have
__
interfered with goal achievement
an ongoing systematic process designed
to evaluate & promote excellence in the
health care provided to clients ; evaluation of level of care provided in health care agency ; limited to the evaluation of the performance
quality assurance program
what are the components of quality assurance
structure evaluation
process evaluation
outcome evaluation
Focuses on the setting in which care is
given
structure evaluation
Focuses on how the care was given
process evaluation
→ Focuses on demonstrable changes in the
client’s health status as a result of nursing
care
outcome evaluation
Follows client’s care rather than
organizational structure ; process rather than individuals ; systematic approach with an intention of improving
quality of care rather than ensuring quality
of care.
quality improvement
rather than individuals, uses a systematic
approach with an intention of improving
quality of care rather than ensuring quality
of care ; national voluntary standards for nursing sensitive care
national quality forum
Refers to the examination or review of
records
audit
→ Is the evaluation of a client’s record after
discharge from an agency
→ Relating to the past events
retrospective audit
→ Is the evaluation of a client¡¦s health care
while the client is still receiving care from
the agency
concurrent audit
