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NRS 125 > Nursing process > Flashcards

Nursing process Flashcards

1
Q

What is the nursing process?

A
  • 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
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2
Q

What are the (5) steps in the nursing process?

A 
assessment
diagnosis
planning
implementation
evaluation
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3
Q

Expand on ASSESSMENT step in nursing process.

A

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
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4
Q

What TYPES OF DATA are collected during assessment?

A

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)

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5
Q

What METHODS of data collection can you use during nursing assessment?

A
  • 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
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6
Q

What are the (2) MAIN PARTS of ASSESSMENT?

A
  1. COLLECTION AND VERIFICATION (gather and cluster unique data including biological, physiological, cognitive, sociocultural, spiritual/ development, environmental, psychological
  2. ANALYSIS OF DATA
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7
Q

What are some sources of data you can use to collect regarding the client?

A
  1. CLIENT
  2. FAMILY and significant others
  3. HEALTH CARE TEAM
  4. MEDICAL RECORDS
  5. LITERATURE
  6. NURSE EXPERIENCE (knowledge from past)
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8
Q

What is your primary source of data?

A
  • usually the CLIENT
  • FAMILY AND SIGNIFICANT OTHERS with children, critically ill persons and mentally handicap, disoriented or unconscious patients
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9
Q

What is your secondary sources of data?

A

for adult clients can use secondary sources of data to confirm what the client provided

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10
Q

How would you go about using the health care team as a source of data?

A
  • communicate with health care team members to gather info about the client
  • every member is a source of information
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11
Q

How would you go about using medical records as a source of data?

A
  • 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
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12
Q

How would you go about using LITERATURE as a source of data?

A
  • use of literature on client illness to INCREASE KNOWLEDGE (important background have an open mind
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13
Q

How would you go about using NURSES EXPERIENCE as a source of data?

A
  • the use of LESSONS LEARNED in previous similar situations

- expertise comes after refining and testing

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14
Q

How would you go about using ADDITIONAL SOURCES as a source of data?

A

NEED CLIENT CONSENT for other sources

  • military records
  • school records
  • employment records
  • past medical records
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15
Q

Expand on DIAGNOSIS step (2) in nursing process.

A
  • 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
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16
Q

What are the steps to the NURSING DIAGNOSIS?

A
  1. ASSESS CLIENT
    - objective/subjective data
    - look for missing data (question)
    - validate data
  2. ANALYZE AND INTERPRET DATA
    - identify normal functional level and indicators of actual/potential dysfunction
    - cluster signs and symptoms to identify patterns
  3. FORMULATE NURSING DIAGNOSIS
17
Q

What is a nursing diagnosis?

A
  • 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
18
Q

What is a medical diagnosis?

A
  • 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
19
Q

What is NANDA international?

A

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
20
Q

What are the (2) main components of nursing diagnosis?

A
  1. DIAGNOSTIC LABEL
    (name of nursing diagnosis approved by NANDA; essence of CLIENT RESPONSE to illness)
  2. RELATED FACTORS
    (is a condition or etiology identified from the clients assessment; ACTUAL OR POTENTIAL RESPONSES;can be changed with nursing intervention)
21
Q

What are some examples of descriptors in nursing diagnosis?

A
  • impaired
  • compromised
  • decreased
  • increased
  • delayed
  • effective
22
Q

Characteristic of NURSING DIAGNOSIS.

A
  • NOT medical
  • cannot change the medical diagnosis
  • its intervention is directed toward behaviour/condition you can treat and manage
23
Q

What are the RULES of NURSING DIAGNOSIS?

A
  • 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
24
Q

Expand on PLANNING step (2) in nursing process.

A
  • nurse PRIORITIZES, PROPOSES STRATEGIS, and creates CARE PLAN with the client and health care team
    (prioritizes issues raised during assessment
25
Q

What are the 3 levels of priority?

A

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

26
Q

Planning also includes ________ and _______ _______.

A

goals and expected outcomes

27
Q

What would planning goals in tail?

A
  • client centred goals
  • collaborative with client and other HCP
  • short term or long term goals
  • one behaviour per goal
28
Q

What would planning expected outcomes encompass?

A
  • 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
29
Q

What does SMART stand for?

A 
specific
measurable
achievable
relevant
time-liminted
30
Q

Expand on IMPLEMENTATION step (4) in nursing process.

A
  • the phase where NURSE AND CLIENT carry out the INTERVENTIONS (plan of care)
31
Q

What are the 3 categories of nursing intervention?

A
  1. nurse initiated (ex. non med pain relief)
  2. physician initiated (ex. meds)
  3. collaborative (ex. team meetings)
32
Q

The NURSE INITIATED INTERVENTION refers to _________ nursing intervention.

A

Independent

33
Q

The PHYSICIAN INITIATED intervention refers to __________ nursing intervention.

A

Dependant

34
Q

COLLABORATIVE INITIATIVE interventions refer to _________ nursing intervention.

A

Interdependent

35
Q

IMPLEMENTATION depends on…

A
  • nursing diagnosis
  • goals expectations and outcomes
  • evidence based
  • feasibility
  • acceptability to the client
  • own competence
36
Q

Interventions can be _____ or ______

A

DIRECT or INDIRECT

37
Q

What is direct intervention?

A
  • ADL’s
  • physical care
  • counselling
  • teaching
38
Q

What is an indirect intervention?

A
  • action that supports the effectiveness of direct intervention
  • communication
  • delegation and supervision
39
Q

Expand on EVALUATION step (5) in nursing process.

A
  • necessary to see if the condition or wellbeing improved

NRS 125 (6 decks)

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