Nursing process

Question 1

What are the 5 steps of the nursing process?

Answer 1

assessment
diagnosis
planning
implementation
evaluation

ADPIE

Question 2

What is the nursing process?

Answer 2

problem-solving approach to identifying, diagnosing, and treating the health issues of clients

Question 3

What are the characteristics/traits of the nursing process?

Answer 3

it is:
planned
problem-oriented (works towards a need)
goal directed
patient centered

Question 4

What is the purpose of assessment?

Answer 4

to establish a baseline of data in regards to needs, health problems, responses to health problems, related experiences, health practices, goals, values, lifestyle, and expectations of HC system

Question 5

What are the 2 steps to assessment?

Answer 5

data collection

data analysis

Question 6

How do you go about collecting data. what should you be gathering and what is important to recognize?

Answer 6

HOW: interview plus physical assessment (description must be clear, concise, and non-judgemental)

WHAT: subjective and objective data

RECOGNIZE sources as primary or secondary. verify with patient to confirm data

Question 7

What are the things that coincide with data analysis?

Answer 7

interpreting data

data clustering (recognizing patterns and clues)

compare with the norm

make a conclusion

Question 8

What is diagnosis?

Answer 8

deliberate and systematic process of data analysis and synthesis which ends in clinical judgement

Make sure it is a nursing diagnosis/intervention

Question 9

What are the three parts of diagnosis?

Answer 9

IDENTIFICATION of patient problems and strengths (this will help you develop a plan)

FORMULATES diagnosis

WRITING a diagnostic statement (has to be something you can treat as a nurse)

Question 10

What are the characteristics of the problem being diagnosed?

Answer 10

must be:

response to a life process, event, stressor

require intervention or resolve

results in ineffective coping

is undesirable

nurse must be competent to treat

Question 11

Why is it important to consider the individuals strengths and weaknesses?

Answer 11

because it will influence the treatment.

Ex. problem may be that they are at risk of skin breakdown because they are incontinent (weakness)

a strength may be that they are very mobile and this will reduce the risk

Question 12

when do you create a diagnosis statement?

Answer 12

in response to an actual or potential problem

Question 13

What are the key words of a Diagnosis statement?

Answer 13

PROBLEM: what is wrong

RELATED TO: why is it a problem. (this is not a medical diagnosis)

MANIFESTED BY: your data, how do you know it is wrong

Question 14

Give an example of a diagnosis statement.

Answer 14

the patient suffers from pain related to a herniated disc manifested by lack of mobility and problems sleeping

Question 15

when do you not include manifested by in a diagnosis statement?

Answer 15

when it is a potential problem

ex. patient is at risk for skin breakdown related to incontinence

Question 16

What is important about making a diagnostic statement?

Answer 16

must not be a medical diagnosis as the problem.

incorrect to say that the problem is a herniated disc, but could say the problem is pain as a result of a herniated disc

Question 17

how do you phrase a nursing diagnosis statement about an actual problem?

Answer 17

“problem related to cause manifested by….

Question 18

How do you phrase a nursing diagnosis statement about a potential problem?

Answer 18

potential for problem related to cause…..

Question 19

What is the planning process?

Answer 19

it is where you set patient centered goals and expected outcomes

select nursing interventions to achieve goals

Question 20

What characteristics should the goals have?

Answer 20

must be clear, measurable, time sensitive, realistic, and mutual/shared

should only address one problem at a time (may have multiple goals, but they must address the same diagnosis)

ex: lungs will be clear at the afternoon assessment

Question 21

What are the 3 steps to planning?

Answer 21

set priorities

develop goals/expected outcomes

select interventions

Question 22

What does setting priorities mean?

Answer 22

depend on needs and desires of patient

which problems require immediate attention and which can be dealt with later

priorities change as patient condition changes.

Question 23

What are the characteristics of goal/outcome statements?

Answer 23

must be:
client centered
involve one behavior (singular)
observable
time limited
measureable
mutual
realistic

Question 24

What is involved in planning?

Answer 24

Selecting interventions:
actions designed to assist patient from present health to that which is described as the goal and measured with expected outcomes

includes activities to assist and enable

or in palliative cases, to experience peaceful death

Question 25

What is the implementation phase?

Answer 25

• application of actions/interventions
• treatment based on clinical judgement and clinical knowledge to enhance patient outcomes
• reflect all dimensions of the individual

Question 26

What are direct care interventions?

Answer 26

things that you yourself are doing

Question 27

What are indirect care interventions?

Answer 27

things you do away from the bedside:

getting a physio consult
documenting
getting the next nurse involved

Question 28

What is the evaluation phase?

Answer 28

process of determining if the goals have been attained

measure of nursing actions and progress toward achieving goals

MODIFICATION: when goals not met, first examine why; necessitates change in plan of care

Question 29

Would you go through modification if goals were met?

Answer 29

yes, may be a better way of doing it that will improve the patients care

Question 30

What are the 5 steps to evaluation?

Answer 30

1. identify evaluative criteria/standards
2. collect data and determine if the criteria and standards have been met
3. interpret and summarize your findings
4. document your findings
5. terminating, continuing care plan as is, or modifying care plan