Nursing process Flashcards
What is the nursing process?
- problem solving approach to IDENTIFYING, DIAGNOSING and TREATING health issues of clients
- process followed by a nurse to ORGANIZES and DELIVERS nursing care
- a SYSTEMATIC APPROACH that applies knowledge from the biological, physical, & social sciences to UNIQUE client situation
- interrelated steps
What are the (5) steps in the nursing process?
assessment diagnosis planning implementation evaluation
Expand on ASSESSMENT step in nursing process.
deliberate systematic collection of data
- establishes BASELINE
- as you go on you can differentiate
- use cues with use of senses and inference which is your judgement or interpretation of those cues
What TYPES OF DATA are collected during assessment?
SUBJECTIVE (clients verbal descriptions of feelings, symptoms, perceptions)
OBJECTIVE (observations and measurements of their health status (temp. BP, description of client behaviour, assessment of wounds)
What METHODS of data collection can you use during nursing assessment?
- CLIENT INTERVIEW (open ended questions
- NURSING HEALTH HISTORY (gain more info)
- PHYSICAL EXAMINATION FINDINGS
- results of PHYSICAL and DIAGNOSTIC TESTS (use comparison and doc thoroughly
What are the (2) MAIN PARTS of ASSESSMENT?
- COLLECTION AND VERIFICATION (gather and cluster unique data including biological, physiological, cognitive, sociocultural, spiritual/ development, environmental, psychological
- ANALYSIS OF DATA
What are some sources of data you can use to collect regarding the client?
- CLIENT
- FAMILY and significant others
- HEALTH CARE TEAM
- MEDICAL RECORDS
- LITERATURE
- NURSE EXPERIENCE (knowledge from past)
What is your primary source of data?
- usually the CLIENT
- FAMILY AND SIGNIFICANT OTHERS with children, critically ill persons and mentally handicap, disoriented or unconscious patients
What is your secondary sources of data?
for adult clients can use secondary sources of data to confirm what the client provided
How would you go about using the health care team as a source of data?
- communicate with health care team members to gather info about the client
- every member is a source of information
How would you go about using medical records as a source of data?
- medical history includes lab and diagnostic test results, current physical findings and the medical treatment plan
- medical records provide BASELINE DATA
- CONFIDENTIALITY
- requires client PERMISSION
How would you go about using LITERATURE as a source of data?
- use of literature on client illness to INCREASE KNOWLEDGE (important background have an open mind
How would you go about using NURSES EXPERIENCE as a source of data?
- the use of LESSONS LEARNED in previous similar situations
- expertise comes after refining and testing
How would you go about using ADDITIONAL SOURCES as a source of data?
NEED CLIENT CONSENT for other sources
- military records
- school records
- employment records
- past medical records
Expand on DIAGNOSIS step (2) in nursing process.
- diagnose WITHIN THE DOMAIN OF NURSING
- use results from YOUR ANALYSIS OF DATA and your IDENTIFICATION of client responses to health care problems
- CLINICAL JUDGEMENT (NANDA)
- forms the basis of interviews and plan of care
What are the steps to the NURSING DIAGNOSIS?
- ASSESS CLIENT
- objective/subjective data
- look for missing data (question)
- validate data - ANALYZE AND INTERPRET DATA
- identify normal functional level and indicators of actual/potential dysfunction
- cluster signs and symptoms to identify patterns - FORMULATE NURSING DIAGNOSIS
What is a nursing diagnosis?
- made by the NURSE
- determines HEALTH PROBLEMS
- describes CLIENT RESPONSE
- responses vary btw individuals
- changes as client RESPONSES CHANGE
- nurse ORDERS INTERVENTION
- GOAL- to direct and develop INDIVIDUALIZED PLAN of care to address health problems
What is a medical diagnosis?
- made by a PHYSICIAN
- refers to the DISEASE PROCESS
- some what uniform btw clients
- remains SAME during disease process
- physician ordered intervention
- GOAL is to PRESCRIRE TXT
What is NANDA international?
North American Nursing Diagnosis Association
- they provide precise definitions
- common language for understanding client needs
- way for nurses to communicate their actions
- distinguish nurses role from other HCP
- focus on scope of nursing practice
- fosters development of nursing knowledge
What are the (2) main components of nursing diagnosis?
- DIAGNOSTIC LABEL
(name of nursing diagnosis approved by NANDA; essence of CLIENT RESPONSE to illness) - RELATED FACTORS
(is a condition or etiology identified from the clients assessment; ACTUAL OR POTENTIAL RESPONSES;can be changed with nursing intervention)
What are some examples of descriptors in nursing diagnosis?
- impaired
- compromised
- decreased
- increased
- delayed
- effective
Characteristic of NURSING DIAGNOSIS.
- NOT medical
- cannot change the medical diagnosis
- its intervention is directed toward behaviour/condition you can treat and manage
What are the RULES of NURSING DIAGNOSIS?
- be SPECIFIC
- within the DOMAIN OF NURSING
- NURSING INTERVENTIONS should NOT be included IN NURSING DIAGNOSIS
- NON-JUDGEMENTAL LANGUAGE
- focus on CLIENTS RESPONSE TO PROBLEM
- NURSING ASSESSMENT must support DIAGNOSTIC LABEL
Expand on PLANNING step (2) in nursing process.
- nurse PRIORITIZES, PROPOSES STRATEGIS, and creates CARE PLAN with the client and health care team
(prioritizes issues raised during assessment
What are the 3 levels of priority?
HIGH PRIORITY
-impaired breathing, safety issue, oxygenation
INTERMEDIATE PRIORITY
- focuses on minimizing complications
LOW PRIORITY
- not always directly related to illness but affect the clients long term health
Planning also includes ________ and _______ _______.
goals and expected outcomes
What would planning goals in tail?
- client centred goals
- collaborative with client and other HCP
- short term or long term goals
- one behaviour per goal
What would planning expected outcomes encompass?
- derived from short term and long term goals
- determines when a specific client-centred goal has been met (action or verb)
- may have multiple
- includes SMART goals
What does SMART stand for?
specific measurable achievable relevant time-liminted
Expand on IMPLEMENTATION step (4) in nursing process.
- the phase where NURSE AND CLIENT carry out the INTERVENTIONS (plan of care)
What are the 3 categories of nursing intervention?
- nurse initiated (ex. non med pain relief)
- physician initiated (ex. meds)
- collaborative (ex. team meetings)
The NURSE INITIATED INTERVENTION refers to _________ nursing intervention.
Independent
The PHYSICIAN INITIATED intervention refers to __________ nursing intervention.
Dependant
COLLABORATIVE INITIATIVE interventions refer to _________ nursing intervention.
Interdependent
IMPLEMENTATION depends on…
- nursing diagnosis
- goals expectations and outcomes
- evidence based
- feasibility
- acceptability to the client
- own competence
Interventions can be _____ or ______
DIRECT or INDIRECT
What is direct intervention?
- ADL’s
- physical care
- counselling
- teaching
What is an indirect intervention?
- action that supports the effectiveness of direct intervention
- communication
- delegation and supervision
Expand on EVALUATION step (5) in nursing process.
- necessary to see if the condition or wellbeing improved
