Nursing Process

Question 1

Nursing Diagnosis (compared to medical Dx)

Answer 1

Statement of pt health status that nurses can identify, prevent, or treat independently/ in collaboration w other health providers

Ex. Pain r/t decreased circulation to feet m/b verbalization of 8/10 on pain scale

Question 2

Medical Dx

Answer 2

Specific disease process using medical terminology

Focuses on disease & pathology

Diabetes mellitus, hypertension, etc

Question 3

Types of nursing Dx

Answer 3

• actual problem
• possible problem/suspected problem
• syndrome- several related problems are present (DM)
• wellness- no problem present, focus on prevention

Question 4

Nursing process: Planning

Answer 4

-planning outcomes/goals
Pt oriented, realistic, r/t nursing Dx, have time frame

-planning interventions
Used to meet pt goals, resolve pt problem, r/t plan of care & nursing Dx & medical plan

Question 5

Nursing process: assessment

Answer 5

Collect data

• interview (pt, family, friends)
• physical assessment
• Dx tests

Question 6

ANA standards for clinical practice (main points)

Answer 6

• define activities specific + unique to nursing
• apply to all nurses
• protect nurse, pt, healthcare institution

Question 7

Objective data

Answer 7

Gathered through physical assessment, measurable

Question 8

Subjective data

Answer 8

Info supplied by pt that cannot be perceived by another person
(Nauseous, pain, tingling)

Question 9

Types of assessments

Answer 9

Initial
Ongoing
Comprehensive
Focused

Question 10

Nursing Process: Dx

Answer 10

Analyze data
identify patterns
Cluster data, draw conclusions 
Identify relevant/ irrelevant data
Identify problems

Use Maslow to identify threats and prioritize to determine nursing Dx

Question 11

Types of nursing interventions

Answer 11

-independent
Nursing orders

-dependent
Nursing actions, carrying out physician orders

-interdependent
joint intervention by RN and others in care team

Question 12

Nursing Process: Implementation

Answer 12

• doing, delegating, documenting
• promote pt participation and adherence to care plan
• collaborate and coordinate care

Question 13

Nursing Process 5 steps

Answer 13

A-assessment
D-Dx
P- planning goals/ outcomes, interventions
I- implementation
E-evaluation

Question 14

How to formulate nursing Dx

Answer 14

• pt problem
• nursing Dx- pick from list
• r/t etiology/ cause of problem
• m/b signs and symptoms- assessment data

Question 15

5 Rights of delegation

Answer 15

Right task- can I delegate this?
Right circumstance- is client stable?
Right person- can delegate do this competently?
Right communication- clear & specific about each task
Right supervision- monitor delegate’s work, intervene if necessary, get/provide feedback, evaluate pt outcomes, ensure proper documentation