Nursing Process Flashcards
Assessing
the nurse collects data
Planning
Prioritizes
Develops strategies to resolve or decrease the patient’s problem
Diagnoses
Identifies human responses to actual or potential health problems
ie at risk for, inability to
Evaluation
Determines effectiveness of plan of care
DVT
Venous inflammation and clot formation impedes blood flow
Client w/ sleep distrubance
normal sleep aids - pillows, back rubs, snack - simplest interventions
Maslow’s 1st priority
physiological - breathing, food, water, sex, sleep, homeostasis, elimination/excretion
Maslow’s 2nd priority
Safety - security of body, employment, resources of the - morality, family, healthy, property
Maslow’s 3rd priority
Love/belonging - friendship, family, sexual intimacy
Maslow’s 4th priority
Esteem - confidence, achievement, respect
Maslow’s 5th priority
Self Actualization - morality, creativity, problem solving
When two nursing diagnoses appear closely related, what should the nurse do first to determine which diagnosis most accurately reflects the needs of a patient?
Review the defining characteristics:
The first thing a nurse should do to differentiate is to compare the data collected to the major and minor defining characteristics of each of the nursing diagnoses being considered.
The nurse performs an assessment of a newly admitted patient. The nurse understands that this admission assessment is conducted primarily to:
Identify important data
This is the primary purpose of a nursing admission assessment.
The guidelines for writing an appropriate nursing diagnosis include all of the following except:
A. State the diagnosis in terms of a problem, not a need
B. Use nursing terminology to describe the patient’s response
C. Use statements that assist in planning independent nursing interventions
D. Use medical terminology to describe the probable cause of the patient’s response
Answer- D
Rationale- A nursing diagnosis is a statement about a patient’s actual or potential health problem that is within the scope of independent nursing intervention. Medical terminology is never part of the nursing diagnosis.
Independent nursing interventions commonly used for immobilized patients include all of the following except:
A. Active or passive ROM exercises, body repositioning, and ADLs as tolerated
B. Deep-breathing and coughing exercises with change of position every 2 hours
C. Diaphragmatic and abdominal breathing exercises
D. Weight bearing on a tilt table, total parenteral nutrition, and vitamin therapy
Answer: D
Rationale- A, B, & C are incorrect. These are not independent nursing interventions because they require a physician’s order.
The nurse would do which of the following activities during the diagnosing phase of the nursing process? Select all that apply.
A. Collect and organize client information
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
E. Develop client goals
B. Analyze data
C. Identify problems, risk, and client strengths
D. Develop nursing diagnoses
Rationale: The diagnosing phase of the nursing process involves data analysis, which leads to identification of problems, risks, and strengths and the development of nursing diagnoses. Collecting and organizing client data is done in the assessment phase of the nursing process. Goal setting occurs during the planning phase.
Assessment Phase
First Step
gathers information about a patient’s psychological, physiological, sociological, and spiritual status
Patient interview
Physical examinations
Referencing a patient’s health history, obtaining a patient’s family history, and general observation
Patient interaction is generally the heaviest during this evaluative phase
Diagnosing Phase
Making an educated judgment about a potential or actual health problem with a patient
Multiple diagnoses are sometimes made
An actual description of the problem (e.g. sleep deprivation) & whether or not a patient is at risk of developing further problems
Used to determine a patient’s readiness for health improvement
Whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
Diagnosing Phase
Making an educated judgment/inference about a potential or actual health problem with a patient (they are hypertensive)
Multiple diagnoses are sometimes made
An actual description of the problem (e.g. sleep deprivation) & whether or not a patient is at risk of developing further problems
The problem part of a nursing diagnosis should state the client’s response to a life process, event, or stressor
Used to determine a patient’s readiness for health improvement
Whether or not they may have developed a syndrome. The diagnoses phase is a critical step as it is used to determine the course of treatment.
Planning Phase
- Plan is developed
- List of priorities is made
- Goals are created: clear, measurable
- Expected beneficial outcomes created
Refer to the evidence-based Nursing Outcome Classification (set of standardized terms and measurements for tracking patient wellness)
The Nursing Interventions Classification may also be used as a resource for planning.
Implementing Phase
Follow through/coordinating the decided plan of action
potentially w/ other disciplines to ensure pt.’s safety Specific to each patient and focuses on achievable outcomes
Monitoring the patient for signs of change or improvement, directly caring for the patient or performing necessary medical tasks, educating and instructing the patient about further health management, and referring or contacting the patient for follow-up
Can take place over the course of hours, days, weeks, or even months.
Outcomes
Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. They should also be realistic and achievable.
consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior.
A desired outcome for a client immobilized in a long leg cast reads; Client will state three signs of impaired circulation prior to discharge. When the nurse evaluates the client’s progress, the client is able to state that numbness and tingling are signs of impaired circulation. What would be an appropriate evaluation statement for the nurse to write?
A. Client understands the signs of impaired circulation
B. Goal met: Client cited numbness and tingling as sign of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
D. Goal not met: Client unable to describe signs of impaired circulation
C. Goal not met: Client able to name only two signs of impaired circulation
Rationale: The goal has not been met because the client states only two out of three signs of impaired circulation. By comparing the data with the expected outcomes, the nurse judges that while there has been progress toward the goal, it has not been completely met. The care plan may need to be revised or more effective teaching strategies may need to be implemented to achieve the goal.
A client centered goal is a specific and measurable behavior or response that reflects a client’s:
Highest possible level of wellness and independence in function.
