Nursing Process Flashcards
What does ADPIE stand for?
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Assessment involves the gathering of information of what sources?
- Pt’s S/S
- Pt Hx
- Subjective findings from the pt (Interviewing)
- Objective findings (Physical Assessment/Vital Signs/Diagnostics/Labs)
Nursing diagnoses are related to the ____ or _____ a patient is experiencing.
needs, problems
Are nursing diagnoses the same as medical diagnoses?
No, they are completely different in that nursing diagnoses are selected based on definitions and defining characteristics
The process of determining priorities and what nursing actions should be performed to help resolve or manage a pt’s problem is done in which step of the nursing process?
Planning
In the planning step, in order for the pt to meet the nursing diagnosis, the nurse should determine what?
- Expected outcomes within a realistic time frame
- Appropriate interventions
Implementation is the process of taking _____ to resolve the pt’s problem/nursing diagnoses.
action
The actions that are taken to resolve a pt’s problem/nursing diagnoses are called _____. When the nurse performs these interventions, it is called _____.
- Interventions
- Implementation
What occurs during Evaluation?
The nurse reflects on the interventions performed and decides whether the pt is closer to achieving the goals and outcomes set in the planning step.
What should you do if the pt does not achieves the goals and outcomes set in the planning step?
- Revise and change interventions
- Revise and change goals
Always tailor interventions and goals to the pt.
A care plan is a documented plan for giving patient care and includes three components which are?
- HCP’s orders
- Nursing diagnoses
- Nursing orders/interventions
How is objective data limited?
It is limited to that which you can detect with your senses – vision, hearing, smell, or touch.
Give some examples of objective data that can be collected via vision.
- Directly observing the pt’s physical characteristics, facial expressions, actions, or behavior
- Directly observe characteristics of bodily fluids (blood, emesis, urine, stool, or drainage)
- Read results of diagnostic/lab test results
- Read reports and documentation within the patient’s medical record
- Read results and discern the function of equipment
- Observe the measured volume of urine or drainage in a graduated container, the volume of fluid remaining in the IV bag and/or the amount of liquid drunk from a cup with graduated markings
- Read reputable sources (medical journals, and multimedia devices) to research medical diagnoses, and treatments
Give some examples of objective data that can be collected via sight.
- Note sounds made by the patient heard (spoken words, belching, passing flatus, crying, moaning, snoring)
- Note sounds heard during auscultation (respiratory, cardiac, GI)
What are some examples of objective data that can be collected via smell?
Detect patient body- or bodily fluid-related odors (foul, sweety, fruity, ammonia-like, sulfurous, fresh, or musty)
What are some examples of objective data that can be collected via touch?
- Assess pulse rate
- Palpate for edema, firmness or softness, nodules, skin masses, or tissue
- Detect the pt’s skin temp
- Detect the moisture of the pt’s skin
- Detect the texture of pt’s skin, hair, or nails
- Measure the strength of muscular contractions
What are some examples of subjective data?
What the patient feels:
- Pain
- Nausea
- Anxiety
- Fear
- Depression
- Discouragement
Primary data refers to information provided by the patient whereas secondary data refers to information from?
- Family members
- Friends
- Patient’s chart
How would subjective data from a pt be documented in the chart?
Pt states/stated “(What they said)”
How would you document objectively when you see a patient is crying?
Pt’s eyes are red and the patient is wiping away tears.
Do not draw a conclusion or inference i.e. the pt is sad, depressed, or discouraged.
When meeting/interviewing a pt for the first time, it is important to establish _____.
Rapport (creating a relationship of mutual trust and understanding)
How can you establish rapport with the pt?
- Introduce yourself and explain your role in the pt’s care.
- Ensure that you have already reviewed the pt’s chart to avoid asking the pt questions that they have already answered and instead validate the information.
- Inform the pt the purpose of the interview and approx. length of time it will take
- Ask some general questions/make small talk to ‘break the ice’ before the interview
Why should nurses be concerned with the pt’s medical diagnoses?
- Pt’s medical diagnoses affect the pt’s abilities to care for themselves and their families; and their quality of life
In addition to asking questions from an interview form, it is important to also ask for additional information (that is not specified on the form) because valuable information can be obtained that would be crucial in providing appropriate nursing care. TRUE or FALSE.
TRUE
If the admission form asks about previous hospitalization and the pt responds by listing two recent surgeries, how can you ask for more additional information concerning this question?
“What about when you were a child, or a young adult? Were you ever hospitalized then?”
If a pt is giving more detail than is necessary for you to obtain relevant information or is going on a ‘tangent’, how can you redirect the pt to the subject at hand?
- “Can you tell me more about the pain you have been experiencing?”
- “After that happened, what did you do to relieve the pain?”
When performing a physical assessment, what are you inspecting for?
- Appearance of and breaks in the skin
- Appearance of the eyes, ears, nose, mouth, chest, abdomen, limbs, and genitals
When performing a physical assessment, what are you palpating for?
Touching the torso and limbs for:
- Pulses
- Temperature
- Moisture
- Vibrations
- Abnormal lumps
During a patient interview, if the pt hesitates before answering a question. How would you respond?
Give the pt time because they may be thinking through an answer. If they continue to hesitate, you may need to reword the question.
During a patient interview, if the pt responds w/ a vague answer using phrases such as “not exactly,” “sort of”, “maybe,” or “you could call it that” in replay. How would you respond?
Ask the pt to provide more detail or to be more specific so that you can get a clear picture of what is being described
During a patient interview, if the pt looks away or acts uncomfortable when you ask a question. How would you respond?
Apologize if the question seems intrusive and explain that the information is necessary for you to better understand how the illness is affecting the pt’s life and relationship.
When performing a physical assessment, what are you auscultating for?
Listening for abnormal sounds in the lungs, heart, or bowels
When performing a physical assessment, what are you percussing for?
Detect abnormalities of internal organs
How is Maslow’s hierarchy of human needs, important in prioritizing nursing diagnoses?
Maslow’s hierarchy identifies human needs in an ascending order of importance
According to Maslow’s hierarchy, humans must meet their physiological needs first before needs on higher steps can be addressed. TRUE or FALSE.
TRUE
Maslow Example: If a pt recently underwent an abdominal surgery and is experiencing pain and not sleep well. Which priority is higher? The ability to learn how to perform a dressing change or pain relief and rest?
Pain relief and rest (physiological needs)
List the 8 levels of Maslow’s hierarchy of human needs in ascending order
- Physiological needs
- Safety and Security
- Love and belonging
- Self-esteem
- Cognitive
- Self-actualization
- Transcendence
According to Maslow’s hierarchy, what are some examples of physiological needs?
- Food
- Air
- Water
- Temperature regulation
- Rest
- Elimination
- Sex
- Physical activity
The need for protection, emotional and physical safety/security, order, law, and shelter is examples of which level in Maslow’s hierarchy?
- Safety and Security
According to Maslow’s hierarchy, what are some examples of love and belonging needs?
- Giving and receiving affection
- Having meaningful relationships
- Belonging to group(s)
According to Maslow’s hierarchy, what should be addressed in the 4th level self esteem?
- Pride
- Sense of accomplishment
- Recognition by others
The need to know, to understand, and to explore are examples of which level in Maslow’s hierarchy?
- Cognitive
What follows the cognitive level in Maslow’s hierarchy and what are some examples of it?
Aesthetic: Symmetry, order, and beauty
What need does the 7th level of Maslow’s hierarchy address?
Need for self-actualization (reach one’s growth potential)
What level is the highest according to Maslow’s hierarchy and what does it entail?
Transcendence of self and helping others self-actualize
What does NANDA-I stand for? And what is it responsible for?
North American Nursing Diagnosis Association International is responsible for creating and maintaining an approved list of nursing diagnoses throughout most countries including the U.S and Canada
How often is the NANDA-I diagnosis list updated/published?
Every 2 years
What are the parts in a 3-part nursing diagnosis statement?
PES Statement:
- Problem (diagnostic label based on the pt’s needs)
- Etiology (“related to”; causative factor(s))
- Signs and Symptoms (“as evidenced by”; supportive data)
In what type of scenario, would a two-part nursing diagnosis (PE or problem and etiology only) statement sufficient?
When the nursing diagnosis expresses for the risk for a problem or possible problem
When the NANDA-I diagnosis falls into the category of “wellness,” “syndrome,” or “specified”, what type of nursing diagnosis statement will be best? 1, 2 or 3-part?
1 part: Clearly states pt’s need w/o requiring further elaboration
1-part nursing diagnosis statement includes wellness, syndrome, and specified. Give examples of each.
- Wellness: “readiness for enhanced…” which means that the pt is willing to improve their lack of hope, knowledge, coping or other needs
- Syndrome: Group of signs and symptoms which already refers to the defining characteristics. Ex. “Post-trauma syndrome”, “frail elderly syndrome”
- Specified: Clearly applies to one defined pt need and adding more information would be redundant. Ex. “Latex allergy response” does not need to be followed by “related to allergy to latex”
In the planning step, why is it important to have a nursing goal?
It provides the overall direction in which one must progress to improve a problem
How do short-term goals and long-term goals differ in when they are expected to be met?
Short-term goals are expected to be met by the time of discharge or transfer to another level of care whereas long-term are not
Identify what is the PES in following nursing diagnosis statement: “Ineffective airway clearance related to secretions in the airways as evidenced by abnormal lung sounds, orthopnea, and dyspnea.”
Problem: Ineffective airway clearance
Etiology: Secretions in the airways
S/S: Abnormal lung sounds, orthopnea, and dyspnea
“Risk for poisoning related to risk factor of confusion,” is an example of what type of nursing diagnosis statement? 1-, 2-, or 3-part?
2-Part (Problem and Etiology (PE) only) Statement
Expected outcomes are statements of _____ action for a patient within _____ time frame and in response to nursing interventions
measurable; specific
What is the standardized classification for nursing expected outcomes?
Nursing Outcomes Classification (NOC) contains a list of 500 expected outcomes designed to coordinate with established NANDA-I diagnoses
Outcome statements should include 4 components, which are?
- A realistic, specific action to be taken by the pt
- An action that the pt is willing and able to perform
- An action that is measurable
- A definite time frame for the action to have been accomplished
Following up with a HCP post-discharge is an example of a short- or long-term goal?
Long term goal
What is the standardized language for nursing interventions?
Nursing Intervention Classification (NIC)
Nursing interventions may only involve direct patient care. TRUE or FALSE.
FALSE. It may involve direct or indirect patient.
What are some examples of direct patient care?
- Bathing
- Teaching
- Listening
- Administering meds
Give some examples of indirect patient care
Nurse is in another setting other than with the pt:
- Documenting care
- Participating in care conferences
- Talking with the HCP
- Receiving new HCP’s order
Nursing interventions can also be classified as independent, dependent, or collaborative. TRUE or FALSE.
TRUE
When you assess a pt’s urine and notice that it is dark yellow and concentrated and that the amount is lower than normal. You decide to put the patient on I/O measurement b/c the pt has a risk for imbalanced fluid volume. What type of nursing intervention is this? Independent, dependent, or collaborative? And why?
Independent because a HCP’s order is not required to perform them. It is instead a nursing order and is a way to obtain more data about the pt’s possible problem
If a pt is c/o constipation, the you would assess the date of the last BM and assess the abdomen. In addition to independent interventions (increasing fluid intake, encouraging high-fiber foods, and assisting w/ ambulation if allowed). You would also administer laxatives or stool softeners as ordered by the physicians. If the pt was still unable to have a BM and further orders were needed you would call the HCP to obtain an order to administer an enema to the pt. The enema portion is an example of an independent, dependent, or collaborative intervention? Why?
Dependent because nurses always need an order from a HCP for administering or changing a pt’s diet, activity level, meds, IV therapy, treatments, diagnostic tests, and discharge
For a terminally ill pt at a long term acute facility, the facility nurse provides care to the resident including meds and treatment and the hospice nurse also provides care but specifically relating to the resident’s terminal diagnosis. This is an example of an independent, dependent, or collaborative intervention?
Collaborative because both nurses provide care to a terminally ill resident.
What should be included in the initial implementation steps (prior to performing a nursing intervention)?
- Checking the HCP’s order. Safety: Always review the order before executing it rather than simply going by what someone tells you is ordered. Be sure the order is appropriate for the pt and nothing has changed to contraindicate it.
- Referring to facility procedures unless you already know them
- Gathering needed equipment and supplies. Check to ensure that a consent form has been signed if needed.
- Obtaining assistance if needed
- Identifying your pt using 2 methods of identification according to facility policy. Safety: Always ensure that you are providing ordered care to the correct patient.
- Introducing yourself to the pt if you have not previously done so. Include your name and title, such as I’m Jane Johnson, a student nurse.”
- Explaining the procedure to the patient, using words the pt understands. Include info about what the pt will do, what the pt will feel, and what the pt is expected to do.
- Provided privacy by closing doors and windows blinds, and if needed asking visitors to step out briefly
- Washing your hands or using hand sanitizer according to facility policy
- Using standard precautions unless otherwise noted
- Using good body mechanics. Safety: Raise the bed to a comfortable working height to prevent injury to your back. Lower the near siderail.
- Making any assessments needed to ensure that the pt still requires the procedure and is able to tolerate it
- Continuing to observe the pt during the procedure to be aware of pain, discomfort, or any other problems
What does the ending implementation steps entail? (after performing a nursing intervention)
- Evaluating the pt’s response to the procedure
- Ensuring the pt is safe and comfortable, in proper body alignment, w/ clean linens and call light within reach
- Safety: Lower the bed to its lowest height to reduce the risk of falls. Raise the bed rails as appropriate and according to facility policy.
- Performing hand hygiene
- Asking the pt if they need anything and informing them when you plan to return
- Leaving the room door open or closed according to the pt’s preference
- Documenting your interventions and their effectiveness according to facility policy
- Properly disposing of used supplies, PPE, and trash, in addition to returning equipment to the proper location
In the evaluation step of the nursing process, you should evaluate whether your nursing interventions brought about the desired outcomes. What types of questions would you ask yourself?
- Are the nursing diagnoses correct?
- Have you established realistic, reachable goals?
- Have you determined the correct priorities for your nursing diagnoses?
- Have you selected and implemented the correct interventions?
- Has the pt’s condition changed?
What are the 4 steps in making a clinical judgement?
- Recognize cutes and analyze them (Pt’s s/s including SOB and cyanotic)
- Formulate a hypothesis (The pt does not have adequate oxygenation
- Take action according to priority (Elevate HOB to expand chest cavity and added supplemental O2 to improve hypoxia. You then assessed for other problems by listening to lung sounds, counting RR, and checking O2 sat)
- Evaluate the effectiveness of your actions (You checked RR and the pt’s color for improvement)
In most hospitals, _____ care plans are the standard where the RN highlights or checks appropriate nursing diagnoses then selects corresponding goals and nursing interventions on a computer screen.
computerized
How do standardized care plans differ from computerized care plans?
Standardized care plans are preprinted documents with typical nursing diagnoses and corresponding nursing interventions choices to coordinate w/ a particular medical diagnosis — help remember most of the interventions for a specific diagnosis, preventing oversight
What type of care plan is frequently used in hospitals and combines a standardized care plan with those of other disciplines. (i.e. physical medicine and rehabilitation, food & nutrition, respiratory, discharge planning/social services)?
Multidisciplinary or collaborative care plan
What is an advantage of a multidisciplinary care plan?
All health care professionals (providers, nurses, RTs, social services workers, PTs, and dietitians) work and communicate with one another – ensuring continuity of care.
Critical/clinical pathways are similar to standardized care plans except what?
Critical pathways are based on the progression expected for each day the pt is in the hospital (uses avg length of stay for a particular medical diagnosis as the basis for progression of care).
How are concept maps/mind maps helpful in care planning?
Serves as visualization of connections made between nursing diagnoses, assessment data, and interventions.
Clinical judgement is the observed outcome of _____ thinking and _____-making.
critical; decision
The National Council of State Boards of Nursing (NCSBN) has created the Clinical Judgement Measurement Model (NCJMM) which serves as a guide for what examination?
Next Generation NCLEX (NGN)
What are the 6 cognitive skills/processes that make up the NCJMM?
1.) Recognize cues (identifying significant data– assessment)
2.) Analyze cues (is the data expected or unexpected?– analysis)
3.) Prioritize hypotheses (what are the pt needs/problems and their priority?– analysis)
4.) Generate solutions (determine interventions for expected outcome– planning)
5.) Take action (Implemented generated solutions– implementation)
6.) Evaluate outcomes (comparing observed outcomes w/ expected ones– evaluation)
Health promotion is the process of teaching good health practices and finding ways to help people avoid _____ health practices.
bad
What is the WHO’s definition of Health?
A state of complete physical, mental, and social-being and not merely the absence of disease or infirmity
What does it mean to use evidence-based nursing practice?
The conscientious and consistent use of scientific research (strength and quality) to make informed decisions in relation to patient-centered care
