Nursing Process Notes Flashcards
In the cognitive domain of learning, their are 4 types
Problem solving
Decision making
Creativity
Critical thinking (using multidepartment in hospital / knowledge from other subject fields)
What is dynamic about the nursing process?
It allows nurses to change their nursing dx
In the assessment phase what occurs?
Collect data (objective and subjective)
Organize data
Validate data
Document data
In the diagnosing phase, what occurs?
Analyzing data
Identify health problems, risks, and strengths
Formulate diagnostic statements
In the planning phase, what occurs?
Prioritizing problems and dx
Formulate goals
Select nursing interventions
Write nursing interventions
In the implementing phase, what occurs?
Reassess the pt
Implement nursing interventions
Supervise delegated care
What occurs in the evaluating phase?
Collect the data related to the outcomes
Compare the data
Modify or terminate the care plan
Draw conclusions
This occurs in the assessment phase:
Collecting objective, subjective and observation data
(observation = palpation, percussion, auscultation)
In the diagnosing phase, the nurse will
Identify the pts strengths, pt weaknesses, problem solve
In the planning phase the nurse will formulate
PTs goals and outcomes (desired outcomes are positive)
The purpose of assessing is to
Gather a baseline or data base about the pts response to health concerns
The two types of initial assessments are
Physical exam (completed within 24 hours of pt arrival) and gather pt history
The primary source of data is who?
The pt
Secondary sources of data are/ or can be
parents
caregivers
What are the two types of interview methods in data collection and the question words associated with them
Directive - quick and closed-ended questions
Nondirective - open-ended questions (how)
List the types of data collection
Observe
Interview (consider pt privacy, comfort, and distance from pt)
Listen
Inspect
List the types of planning
Initial
Ongoing (done by all nurses who work with pt)
Discharging
Which parts of the nursing process address the pt?
Assess
Diagnosis
Planning
Evaluation
Which part of the nursing process address the nurse?
Implementing
A NANDA two-part diagnosis only includes the __________ and ________.
Problem and Etiology (This is a Risk diagnosis)
A NANDA three-part diagnosis includes
Problem
Etiology
Signs and symptoms
What is the advantage of a NANDA three-part diagnosis?
Including the s/s means that we know what is causing the problem and shows proof (this is an Actual diagnosis)
What are the types of nursing diagnosis?
Actual (3 part)
Risk (2 part)
Health promotion (wellness)
Syndrome
All NANDA diagnosis do this
Promote taxonomy of nursing
Acute pain addresses which domain in the NANDA diagnosis
Safety
Which domain in the NANDA diagnosis does respiratory address?
Safety
What is initial planning?
Client contact and continues until patient leaves
Hands on exam
How are pts goals written?
The patient will …
When planning, goals should be SMART
Specific
Measurable
Attainable
Realistic
Time-framed
What are the two reasons to reassess a pt?
To identify if the intervention is still needed
To see if their health status changed
Describe what etiology is
The cause of the problem
Signs and symptoms are considered _____ in the NANDA nursing dx
Proof
List the levels of physiological priority
High (life threatening)
Medium (health threatening)
Low (developmental needs)
List and describe the three domains of learning
Cognitive -what you know
Affective (Interpersonal) - how you learn/ know
Psychomotor (Technical) - hands on
Describe an informal nursing care plan
a strategy of action that exist in the nurses mind
Describe formal nursing care plan
computerized guide that organizes information about the pts care
Describe a standardized care plan
Care plan for a group of pts with common needs
Describe individualized care plan
Tailored to meet the unique needs of a specific pt
