Nursing Process Flashcards
What is the Nursing Process?
science of nursing based on a framework
What are the Nursing standards?
- Assessment
- Diagnosis
- Outcome identification
- Planning
- Implementation
- Evaluation
- Quality of practice
- Education
- Professional practice evaluation
- collegiality
- collaboration
- Ethics
- Research
- Resource utilization
- Leadership
What is the focus of the nursing process?
To identify potential risk, expected outcomes and provide a systematic and organized plan of care for the preoperative pt
Characteristics of the nursing process?
- Standard
- Integrative
- Systemic
- Dynamic
- Interpersonal
- Goal and outcome oriented
- Universal
Standard
standard of practice by which all nurses are expected to perform competently
Intergrative
Incorporates an holistic, caring perspective, research and evidence based perspective to integrate the science and art of nursing to meet the pt. needs
Systemic
Suggest orderly sequence of activities and problem solving activities
Progresses towards identified expected outcomes
scientific and evidence based
Dynamic
An integration of single action that occur at the same or similar time
flexible- can be modified to pt needs
Interpersonal
Pt. centered
outcome focused
Not tasked centered
Goal and outcome oriented
Matched with corresponding diagnosis and intervention
Most important to pt care establish
promotes continuity of care and provides direction on how to proceed
Universal
provides working frame for all nursing activities
Assessment
- collection data
- pt history and physical
- medical record review
diagnosis-purpose
analyze assessment data to determine pt diagnosis
*preoperative diagnosis?
- anxiety ( unfamiliar environments, impending surgery)
- Fear ( potential outcome)
- Grieving ( loss of body parts)
- Risk for imbalanced fluid volume ( NPO status, preexisting condition)
- imbalanced nutrition less than body requirement
- Risk for aspiration ( NPO status, preexisting condition)
*intraoperative diagnosis?
- Risk for impaired skin
- risk for peripheral neurovascualar dysfunction
- Risk for infection ( break in aseptic technique)
- Risk for preoperative positioning injury
- Decreased cardiac ( anesthetic medication, decreased mobility, venous pooling)
- Ineffective breathing mechanism (anesthetic medication)
- Hypothermia (cool room, cool prep, exposure for surgery, open body cavity)
- Risk for imbalance fluid ( loss of body fluid, preoperative NPO status)
- Risk for injury ( incorrect counts, equipment malfunction, burns, improper use of ESU, pooling of prep solution, falls)
- Postoperative diagnosis?
- Impaired spontaneous ventilation (tongue blocking airway, retained secretions, surgical procedure)
- Risk for bleeding ( blood and fluid loss)
- Risk for deficit fluid volume ( inadequate volume)
- Impaired gas exchange( excess and deficient in oxygenation)
- Acute pain (surgical incision)
- Hypothermia ( core temp < 36 C)
Identification of outcome
RN identifies expected outcomes for individualized plan of care
eg. pt is free from signs and symptoms of injury related to positioning
Planning
establish goals and outcomes
eg. select interventions to assess baseline skin condition, appropriate positioning aid, plan for post operative skin assessment
Implementation
To carry out a plan of care
eg. assess skin condition pre and post op
pad and position patient to maintain appropriate body alignment and promote skin integrity
Evaluation
Identify if expected outcomes were met
eg. evaluate for physical injury to skin and tissue
Assessment key words on exam?
- Collects
- Identifies
- Confirms
- Verifies
Diagnosis key words on exam?
- Risk for
- Statement such as Fear
- Objective statement such as hypothermia
Identification of outcome key words on exam?
Pt will be free from
Plan of care key words on exam?
focus is the planning
Implementation as key words on exam?
Actions or interventions to be taken by the RN
- performs
- provides
- implements
Evaluation key words on exam?
- Evaluate
2. Ensures
