Nursing Process & Nursing Diagnosis

Question 1

Nursing Process

Answer 1

The framework of the nurse /TANNER’S CLINICAL JUDGMENT:
1. Introduction

2. Assessment – Bedside assessment, clinical notes sheet /NOTICING
3. Diagnosis – Nursing diagnosis /INTERPRETING
4. Planning – Outcomes or goals
5. Implementation – Nursing interventions /RESPONDING
6. Evaluation /REFLECTING

Question 2

Assessment

Answer 2

Prior to entering pt’s room:

1. CC
2. HPI
3. PMH
4. Past surgical history
5. PSH (Present social history)
6. Relevant lifestyle and social history
7. Additional – Allergies, isolation status, diet, restrictions (fluid, activity), other (VS frequency)

Data:

1. Subjective – What the pt says (in quotes)
2. Objective – What the nurse observes

Ask:

1. Pt’s story
2. Open-ended questions (NOT yes/no) – What made them come? Characterize their pain

Question 3

Nursing diagnosis

Answer 3

Formulated using the medical diagnosis, nursing assessment, and pt’s story

Types of nursing diagnosis:

1. Problem-focused or actual – Reflects a priority theory (i.e. Maslow’s hierarchy of needs)
2. Risk
3. Health promotion

Question 4

Maslow’s hierarchy of needs

Answer 4

Address (in order of):
1. Physiological needs

2. Safety needs
3. Social belonging
4. Esteem
5. Self-actualization

Question 5

Diagnosis #1: Problem focused or actual

Answer 5

3 Parts: (NANDA DIAGNOSIS) r/t (ETIOLOGY) secondary to disease aeb (SYMPTOMS/ASSESSMENT)

i.e. Excess fluid volume r/t impaired secretion of sodium and water (secondary to HF) aeb pain 9/10 in legs, 3+ pitting edema of legs, SOB, crackles in lungs.

Question 6

Diagnosis #2: Risk

Answer 6

2 Parts: (RISK DIAGNOSIS) r/t (CHARACTERISTICS/OBSERVABLE FACTORS)

i.e. Risk for aspiration r/t neck surgery and inability to swallow easily.

Question 7

Diagnosis #3: Health promotion

Answer 7

Clinical judgment concerning motivation and desire to increase well being

Focuses on being as healthy as possible

Question 8

Planning: Outcomes or goals

Answer 8

Must be:

1. Pt-focused
2. Specific or quantifiable
3. In a realistic time frame

Question 9

Implementation

Answer 9

Interventions are nurse-focused items

First intervention will always be to assess

Question 10

Evaluation

Answer 10

Address if each outcome was:

1. Met
2. Partially met
3. Not met