Nursing Process Flashcards
What is the nursing process ?
A framework nurses use to apply critical thinking in nursing practice for making clinical decisions
What are the 5 components of ADPIE ?
-Assessment (subjective & objetive data)
-Diagnosis (actual vs at risk, i.e do not use medical diagnosis terms to describe)
-Planning (proctorize goals & expected outcomes)
-Implementation (standardized nursing interventions)
Evaluation (
Describe Assessment
-The first thing nurses always do is assess the patient/client
-This is conducted during physical examination
What are the 2 types of assessments ?
-Patient-centered interview+physical exam
-Periodic assessments+physcial exam
What is a comprehensive assessment ?
A full head-to-toe assessment
What is a focused assessment ?
-A more targeted assessment of the are of concern
-Ask any questions related to that are of pain
-Specifically focusing on what the patient came in complaining about
Describe data being gathered when assessing a patient.
Consists of patient’s perceived needs, health problems, and responses to problems
What are the two types of data ?
-Subjective data
-Objective data
Describe subjective data
-The pt’s verbal description of their health problems gathered during interviews (informal+formal)
-Includes the pt’s feelings, perceptions, and self-reported symptoms
-Often reflect physiological, social, or psychological changes
*Example: pt says “Feels like an elepahnt is sitting on my chest”
-Pain is subjective
Describe Objective data
-The findings resulting from observation of the pt’s behavior and clinical signs and direct measurements
The data we can measure or observe in out pt
*Example: Vital signs, lab data,BP
What are sources of data ?
-Primarily from the pt, family, medical records, and diagnostic lab data
-We’re always comparing data with the normal limits
What are the 4 methods of assessment ?
- Patient-centered interview
- Nurse’s experience
- Environment
4.Nursing Health History
Explain the Patient-centered interview method
-Relationship-based and organized conversation focused in learning about a pt’s concerns and needs
-Where you develop a rapport, ask open-ended questions, and develop relationship with the pt
Explain the Nurse’s experience method
-Can be dependent on the level of experience for the nurse
-Provides a background for each clinical encounter with a pt
-Reflect on personal experience to help you explore a pt’s situation
-Experience in caring for pt’t is an important source of data
-As a new nurse, use systematic and analytical method for assessment
-Experience with nursing skills as important for an accurate assessment
Explain the Environment method
-Consider the setting where you perform an assessment
-Use each pt encounter as a time to perform assessment and focus on the pt priorities
Explain the Nursing Health History method
-Important to conduct a thorough health history
-Ask the right questions
-Ask th ept to explain why thye came for health care, listen, proceed at reasonable pace, and ask open-ended questions
What are the components of the nursing healthy history ?
-Present illness or health concerns (PQRST)
-Use PQRST to guide your assessment
-Data documentation
What does PQRST mean ?
P-provokes
Q-quality
R-radiate
S-severity
T-time
Concept Mapping
Apart of the assessment process
-A visual representation that allows nurses to graphically illustrate the connections between a pt’s health problems
-Allows nurses to obtain hollistic perspective of health care needs
Explain Data Documentation
-With all the info and findings collected, we document into the pt’s medical record
-The last component of the assessement
-Legal and professional responsibility
-Requires accurate+approved terminology+abbrevations
Describe Diagnosis
After we assess, we develop a nursing diagnosis
What is data clustering ?
-Sets of assessment findings/defining characteristics
-A group of data elements, the signs or symptoms gathered during assessment
-Identifying pt’s problems from a nursing perspective
-Organize data
-Look for meaningful patterns
What is the nursing diagnosis (dx) ?
-A clincal judgment in response in repsonse to a pt’s potential helath problem (not a medical dx (what physicians do)
-Identifying a problem nurses can manage
*Ex: “Impaired comfort r/t itching”, “risk for electrolyte imbalance r/t renal dysfunction”, “disturbed body image r/t lesions on body”, “deficient fluid volume r/t active fluid loss as evidence by(aeb) excessive diuresis”
Proper Nurse Dx
-Must have a r/t statement
-If evidence exist add “aeb” (as evidence by)
ex:Deficient fluid volume r/t active fluid loss aeb excessive diuresis
Data interpretation
-Look for defining characteristics )assessment findings)
-Signs and symptoms that supprot identifying the pt’s problem freom a nursing perspective
Nurse’s independent practice
-North American Nursing Dx Association (NANDA-I)
-Ex: Symptom relief and client education
-Use a common language to unde the pt’s needs
What are the 3 types of nursing dx ?
-Actual (Problem focused) nuring dx
-Risk nursing dx
-Health promotion/Pt education nursing dx
Explain Actual (problem focused) nursing dx
-Describes undesirable human responses to existing problems or concerns of a pt
Ex: a pt has a tissue injury on their butt, so they developed a pressure ulcer because they’ve been in bed for 3 weeks
Explain Risk nursing dx
-Describe human responses to health conditions.life processes that may develop
Ex: A pt just came out of surgery, their skin is intact, but they are at risk for tissue injury because they will be immobile due to their surgery
What are the components of a nursing dx ?
-Diagnostice label or dx
-Related factors (r/t)
-Definition (NANDA-I)
-Associated condition
-Support of the diagnostic statement
Describe planning step in the nursing process
-After we assess and develop a nursing dx, the next step is to plan our outcomes
-Based on priority
Classification of priorities
-High
-Intermediate
-Low
Maslow’s Hierarchy of needs
-ABC’s (first priority)
Airway
Breathing
Circulation
What are Maslow’s Hierchy of Needs ?
- Self Actualization
- Esteem Needs
- Social Needs
- Safety needs
- Physiological Needs
*In an acute care setting, emphasis is to meet the pt’s physiological and safety needs
What are the Nursing Outcomes Classifications (NOC) ?
SMART ACRONYM
S-specific
M-measurable
A-attainable
R-realistic
T-timed
Planning outcomes include 3 types of interventions, name them
-Nurse-initiated
-Health care provider-initiated
-Collaborative
Explain Nurse-initiated intervention
-Independent in nursing intervention where a nurse initiiated in response to a nursing dx without supervision/direction
Ex: Moving a pt up and down in the bed, getting them comfortable
Explain Health care provider-initiated intervention
-Dependent nursing intervention that requires order from a health care provider
Ex: Administering pain medication
Explain Collaborative intevention
-Interdependent interventions are therapies that require the combined knowledge, skill, and expertise of multiple health care providers
Ex: Collaborating with a dietitian or PT on how to manage a pt’s situation
What are the 3 planning nurse care plans ?
-Nursing care plans
-Interprofessional care plans
-Concept maps
Explain Nurisng care plan
-Includes the nursing dx, expected outcomes, individualized nursing interventions, and evaluation findings
Explain Interprofessional care plans
-Contributions from all nurses, providers, other health professionals involved in pt care
Explain concept maps
-Students
-Visual representation of all of a pt’s dx with diagram interventions for each
Describe Implementation in the nursing process
-Next we implement the nursing care
-This step begins after a pt’s plan of care
-Before you implement, REASSESS
-Review the set of all possible nursing interventions
-Review all possible consequences associated with each possible nursing action
-Determine the probability of all possible consequences
Make a judgment of the value of that consequence to the pt
Explain standard nursing interventions
-Allow nurses to deliver the most clinically effective care to improve pt outcomes
-Captures pt care info that can be shared across care settings
-Based on pt’s individual needs+ preferences
-Using a common language
What are the 3 interventons included in the implementation step in the nursing process ?
-Clinical practice guidelines+protocols
-Standing orders
-Nursing intervention classification
Explain clinical practice guidelines + protocols
-One form is a care bundle
-Group of interventions related to a disease process/condition
Explain standing orders
Preprinted documents containing medical orders for rountine therapies, monitoring guidelines, and diagnostic procedures for specific pts with identified clincal problems
Explain Nurisng Intervention Classification (NIC)
Using standardized language nurses can use to identify treatments they perform, organize info, and provide a language to communicate with pts. families, and other providers
Implementation process
-First thing nurses dois reassess pt
-Gather additonal info to ensure the plan of care is complete, current, and appropriate
-Confirm you’ve selected appropriate interventions
-Helps to decide whether the proposed nursing actions are still appropriate for a pt’s level of wellness
-After you reassess and if you need to add/modify the plan of care you need to review and revise the care plan
-Next you need to prepare for implementation by organizing time and resources
1. Equipment
2.Personal
3. Environment
4. Patient
-Lastly, anticipating and preventing complications
Describe the Evaluation step in the nursing process
-The last step of the nursing process is evaluation
-Evaluation is an ongoing process
-Always evaluating when we enter a pt’s room
-Always documenting
-Going back and evaluating if what was done was effective
-Reassess to know if the intervention worked
Describe the evualtion process
-Examine results
-Recognize errors or unmet outcomes
-Correct errors
-Revise the care plan
-Always document
Genral critical thinking/Scientific method
-Systematic approach to gather data + solve problems
-Uses reasoning (5 steps of sceintific method)
-Gathering data and comparing data
Ex: vital signs data and comparing it to previous results
What are the steps in the scientific method ?
- Identify the problem
- Collect data
- Formulate a question or hypothesis
- Test the question or hypothesis
- Evaluate results of the test or study
