Nursing Process PPT Flashcards
______ decision making requires critical thinking.
clinical
Clinical decision making requires critical thinking. This separates professional nurses from technical and ______ staff.
ancillary
Nurses need to seek knowledge, act quickly, and make sound ______.
clinical decisions
Nurses are guided by ____ to become an informed critical thinker.
EBP (evidence based practice)
Critical thinking is a continuous process characterized by open-mindedness, continual inquiry, and perseverance, combined with a willingness to look at each _____ patient situation and determine which identified assumptions are true and relevant.
unique
_______ is recognizing that an issue exists, analyzing information, evaluating information, and making conclusions
critical thinking
Critical Thinking Skills (6)
Interpretation Analysis Inference Evaluation Explanation Self-Regulation
Nurses use the nursing process to determine client/family level of wellness and ________.
need for assistance
Nurses use the nursing process to _______ (physical and emotional)
provide care
Nurses use the nursing process to teach, guide and ______
counsel
Nurses use the nursing process to implement _______ aimed at prevention and assisting the client to meet his or her needs.
interventions
The nursing process is a variation of ______.
scientific reasoning
The five steps of the nursing process allow you to be organized and have a _______.
systematic approach
The five steps of the nursing process allow you to learn to make ______ about the meaning of a patient’s response to a health problem or generalize about the patient’s functional state of health.
inferences
By using the nursing process, in particular the assessment portion, a ____ begins to form.
pattern
The five steps of the nursing process
Assessment Diagnosis Planning Implementation Evaluation
During the assessment you collect information from primary and ______ sources.
secondary
During ______ you gather the “patient’s story” along with interpreting and validating the information to form a complete database.
assessment
The primary source to collect information from is the ____. Every time a piece of information is added to the health record it becomes another part of the “patient’s story”
patient
The secondary source of information can come from _______, friends, other health care providers, scientific literature, and the nurse’s experience.
family members
The purpose of assessment is to establish a _____. This includes patient’s perceived needs, health problems, and _______.
database
responses to these problems
Critical thinking skills help you to synthesize relevant information and use it is a _____ way.
purposeful
During the assessment you gather information and it includes information from the _____.
physical examination
During the assessment, collect data. With this information ______ cues, then make inferences. Identify patterns and problem areas.
cluster
Interview Techniques (3)
open-ended vs closed ended questions
back channeling
probing
Because a patient’s report includes subjective information, ____ data from the interview later with objective data.
validate
Obtain information (as appropriate) about a patient’s physical, ______, emotional, intellectual, social, and spiritual dimensions.
developmental
Information about work, _____ and home surroundings comes from a thorough health history.
social
____ is when you gather information about the patient’s condition.
assess
____ is when you determine if goals and expected outcomes are achieved.
evaluation
_____ is when you perform the nursing actions identified in planning.
implementing
___ is when the nurse identifies the patient’s problems.
diagnose
_____ is when you set goals of care and desired outcomes and identify appropriate nursing actions.
planning
There are two stages of assessment which include the collection and verification of data as well as the _____.
analysis of data
The analysis of data includes recognizing patterns or trends, compare the data with expected standards and reference ranges, and arrive at conclusion to _______.
guide nursing care
_____ information is obtained from teh client - patient’s feelings, perceptions, and reported symptoms.
subjective
____ information is obtained from the physical assessment, vital signs, laboratory and diagnostic results, patient’s behavior, observations made.
objective
Two comprehensive Assessment Approaches
general to specific
problem oriented approach
_______ is a visual representation that allows nurses to graphically illustrate the connections between a patient’s health problems
concept mapping
Concept mapping allows nurses to obtain a______ perspective of health care needs
holistic
To conduct an accurate and complete assessment, you need to consider a patient’s ______ background.
cultural
When cultural differences exist between you and a patient, respect the _____ and be sensitive to a patient’s uniqueness.
unfamiliar
If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong _____.
diagnostic conclusion
If you are unsure about what a patient is saying, ask for clarification to prevent making the wrong _____.
diagnostic conclusion
NANDA stands for
North American Nursing Diagnosis Association
_______ allows the nurse to select relevant and appropriate nursing interventions
nursing diagnostic statements
Nursing diagnostic statements provides a _______ of a patient’s problem that gives the health care team a common language for understanding patients’ needs.
precise definition
A _________ allows nurses to communicate what they do among themselves and with other health care professionals and the public.
nursing diagnostic statement
A nursing diagnostic statement distinguishes the nurse’s role from that of the _______.
physician or other health care provider
A nursing diagnostic statement helps nurses focus on the ____ of nursing practice.
scope
Identification of a disease condition based on specific evaluation of signs and symptoms is considered a _____ diagnosis.
medical
Clinical judgment about the patient in response to an actual or potential health problem is considered a _____ diagnosis.
nursing
Actual or potential physiological complication that nurses monitor to detect a change in patient status is considered a ____.
collaborative problem
Describes human responses to health conditions or life processes is the _____ diagnosis which exists already.
nursing
Describes human responses to health conditions/life processes that may develop which has the _____ or “risk for” nursing diagnosis.
potential
A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human health potential is considered the ________ nursing diagnosis.
health promotion
What are the 3 parts to developing a Nursing Diagnosis?
- Diagnostic Label (approved by NANDA)
- “Related to” factor (etiology; causative factor for the diagnosis)
- Evidence or Defining Characteristics
“Risk for” does not have evidence
When developing a ______ you use the diagnostic reasoning process which involves using the assessment data you gather about a patient to logically explain a clinical judgment or the diagnostic label for a nursing diagnosis..
nursing diagnosis
Cluster data and identify _____ and problems to develop a Nursing Diagnosis such as impaired skin integrity and risk for impaired skin integrity.
patterns
______ factors are pertinent to the diagnoses.
related to
Developing a nursing diagnosis allows you to _______ the diagnosis for a specific patient.
individualize
When you are ready to form a plan of care and select nursing _______, a concise nursing diagnosis allows you to select suitable therapies.
interventions
______ are clinical criteria or assessment findings used in developing a nursing diagnosis.
Symptoms
Data clusters are patterns of data that contain defining characteristics are considered clinical criteria that are observable and _____.
verifiable
A ______ is a set of signs or symptoms gathered during assessment that you group together in a logical way.
data cluster
Each clinical criterion is an objective or subjective sign, symptom, or risk factor that, when analyzed with other criteria, leads to a _____.
diagnostic conclusion
Impaired….. r/t immobility as evidenced by (AEB) disruption of epidermal and dermal skin of the right heel.
?
Diagnostic Statement Guidelines
- Identify the patient’s response, not the medical diagnosis.
- Identify a NANDA-I diagnostic statement rather than the symptom.
- Identify a treatable cause or risk factor rather than a clinical sign or chronic problem that is not treatable through nursing intervention.
- Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
- Identify the patient response to the equipment rather than the equipment itself.
- Identify the patient’s problems rather than your problems with nursing care.
- Identify the patient problem rather than the nursing intervention.
- Identify the patient problem rather than the goal of care.
- Make professional rather than prejudicial judgments.
- Avoid legally inadvisable statements.
- Identify the problem and its cause to avoid a circular statement.
- Identify only one patient problem in the diagnostic statement.
_____ contains two parts: write measurable patient/client outcomes (PO) and
Identify nursing interventions to accomplish the outcomes (PI)
Planning
The _______ and interventions are designed to change the client’s nursing diagnosis/problem.
patient outcomes
A broad statement that describes the desired change in a patient’s condition or behavior is called a ____.
goal
An _____ is a measurable criteria to evaluate goal achievement
expected outcome
_______ objective behaviors or response expected within days, weeks, months.
long term
An aim, intent, or end.
goal
________ outcomes are time limited objective behaviors or response expected within hours to a week.
short term
________ outcomes are time limited objective behaviors or response expected within hours to a week.
short term
Goals must be _____ centered.
patient
Guidelines for Goal/Outcome Writing SMART. All goals must be client centered and _____.
mutual
Goal/Outcome Writing SMART
Singular, Specific Measurable (observable) Attainable Realistic Timely
The order of priorities changes as a patient’s _____ changes.
condition
_______ begins at a holistic level when you identify and prioritize a patient’s main diagnoses or problems.
Priority setting
Patient-centered care requires you to know a patient’s preferences, values, and _______.
expressed needs
______ care is a part of priority setting.
Ethical
Planning: Establishing priorities
High- Emergent
Intermediate
Low-affect’s patient’s well-being
Planning : Establishing Prioririties = Maslow’s Hierarchy of Needs
A,B,C’s Airway Breathing Circulation Time Consuming
When planning interventions an activity is done for an with a patient and includes ______.
frequency.
When planning interventions consider (4)
activity is done for and with the patient
specific/safe
orders that are relevant to this ND
removes or reduces related factors that contribute to nursing diagnosis
When planning interventions it must be specific/safe which leads to goal attainment and is _____ to the patient.
individualized
When planning interventions the ____ must be relevant to the nursing diagnosis.
orders
When planning interventions remove or reduce _____ that contribute to the nursing diagnosis.
related factors
Three types of interventions
nurse initiated
physician initiated
collaborative
A ___ initiated interventions is independent and include actions that a nurse initiates.
nurse
A _____ initiated intervention is dependent and requires an order from a physician or other health care professional.
physician
A ____ intervention is interdependent and requires a combined knowledge, skill, and expertise of multiple health care professionals.
collaborative
Six factors to consider in the selection of interventions
Characteristics of nursing diagnosis
Goals and expected outcomes
Evidence base for interventions
Feasibility of the interventions
Acceptability to the patient
Nurse’s competency
Types of interventions
Assessment Dependent Independent Interdependent Teaching Referral/Community resources/consultation Pharmacology Protocols Standing orders Preventive measures
____ is a type of intervention that always is the number one intervention listed.
assessment
A ____ intervention is HCP initiated.
dependent
______ interventions are also known as collaborative.
interdependent
There are referral/______/consultation interventions.
community resources
One type of intervention is _____ (medications)
pharmacology
Protocols, standing orders and ______ are also considered types of interventions.
preventative measures
When preparing for ______ or _____ interventions, do not automatically implement the therapy, but determine whether it is appropriate for the patient.
physician-initiated
collaborative
The ability to recognize _____ therapies is particularly important when administering medications or implementing procedures.
incorrect
Planning involves consultation with members of the _______.
health care team
__________ to seek the expertise of a specialist to identify ways to handle problems in patient management or in planning and implementation of therapies.
Consultation
Consultation occurs at any step in the nursing process, most often during _____ and ________.
planning
implementation
A critical time, when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions is during _____.
change of shift
______ communicates information from offgoing to oncoming patient care personnel = “Nurse handoff”
Change-of-shift report
Focus your change of shift reports on the nursing care, treatments, and _______ documented in the care plans.
expected outcomes
______ and _______ are systematically developed
set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health
care for specific clinical situations.
guidelines and protocols
_______ are preprinted documents containing orders for
the conduct of routine therapies, monitoring guidelines, and/or
diagnostic procedures for specific patients with identified clinical
problems.
standing orders
With interventions you need to anticipate and ______ complications.
prevent
To anticipate and prevent complications with interventions you need to (5)
Identify risks to the patient.
Organize resources and care delivery.
Adapt interventions to the situation.
Evaluate the relative benefit of a treatment vs. the risk.
Initiate risk prevention measures.
_____ involves initiation of the nursing care plan and performing interventions.
implementation
During the implementation stage, _______ of appropriate interventions occurs.
delegation
During the implementation stage, _______ of appropriate interventions occurs.
delegation
Skill used during the implementation of care include psychomotor, interpersonal, and ______.
cognitive
During the implementation of care you are performing continuous ______, trying to promote client participation, and coordinate care.
assessment
When using critical thinking in implementation check your knowledge and ______.
abilities (policies)
When using critical thinking in implementation review the set of all possible _______.
nursing interventions
When using critical thinking in implementation review all possible ______ associated with each possible nursing action.
consequences
When using critical thinking in implementation determine the probability of all possible _____.
consequences
When using critical thinking in implementation make a ____ of the value of that consequence to the patient.
judgement
When using critical thinking in implementation organize your work to establish _____ and prepare supplies and equipment.
feedback points
When using critical thinking in implementation prepare the ____.
client
Implementation skills involve cognitive skills, interpersonal skills, and ______.
psychomotor skills
____ skills involve the application of critical thinking in the nursing process
cognitive
_______ skills involve developing a trusting relationship, expressing a level of caring, and communicating clearly with a patient and his or her family
interpersonal
______ skills involve the Integration of cognitive and motor activities.
psychomotor
_____ care are treatments performed through interactions with patients
direct
____ care involve treatments performed away from the patient but on behalf of the
patient or group of patients.
indirect
Managing the patient’s environment (e.g., safety and infection control) is an example of _____ care.
indirect
Medication administration is considered _____ care.
direct
Insertion of an IV infusion is considered ____ care.
direct
Counseling during a time of grief is considered ____ care.
direct
Documentation is considered _____ care.
indirect
Interdisciplinary collaboration is considered ____ care.
indirect
_____ is transferring responsibility while retaining accountability.
delegation
Delegation includes _____.
supervision
You can not delegate:
An intervention that requires independent, specialized, nursing knowledge, skill, or judgment
You can not delegate an intervention of client education, ESPECIALLY, with a new diagnosis!!!
Five Rights of Delegation
Right Task Right Circumstances Right Person Right Direction/communication Right supervision
The final step of implementation is _____.
documentation
_____ is a record of nursing activities and the clients response.
documentation
If it is not _____, it didn’t happen. The medical record is a legal document and cause legal issues if information is not documented or documented incorrectly.
documented
If it is not _____, it didn’t happen. The medical record is a legal document and cause legal issues if information is not documented or documented incorrectly.
documented
Nurses implement care to meet patient ____.
goals
At times, ______ interventions may be needed.
multiple
Priorities help nurses to anticipate and _____ nursing interventions.
sequence
Patient ______ means that patients and families invest time in carrying out required treatments.
adherence
During the evaluation portion assess the patient’s progress toward goals, the effectiveness of nursing care plan, and the _______ in the health-care setting.
quality of care
Evaluation is always _____.
ongoing.
During the evaluation stage, evaluate if the client outcomes/goals where met, partially met or, _____.
not met
If not met, what do you do?????
How Do I Evaluate Client Progress?
Review outcomes
Collect reassessment data
Judge goal achievement
Record the evaluative statement
Evaluate collaborative problems
Nursing care helps patients resolve actual health problems, prevent potential problems, and ____.
maintain a healthy state
When evaluating the effectiveness of interventions document results and _____ care plan.
revise
When evaluating the effectiveness of interventions collaborate with the patient and the ____.
family
When evaluating the effectiveness of interventions use evaluative ____.
measures
When evaluating the effectiveness of interventions interpret and ______ findings.
summarize
Evaluation: Clinical reasoning questions
How did the patient tolerate the intervention?
Were there any identified problems?
Was any additional equipment needed?
Was the time frame appropriate?
Were the appropriate personnel involved?
Common errors of evaluations
Failing to evaluate systematically
Failing to record results
Failing to use reassessment data to reexamine and modify the care plan
When discontinuing a care plan you need to assess if the goal has been met, does the _____, and document the discontinued plan.
patient agree
The steps involved in the modification of an existing written care plan
Revise data assessment.
Revise/redefine the nursing diagnoses.
Revise specific interventions.
Determine how to evaluate whether you have achieved outcomes.
When modifying a care plan it involves reassessment, redefining diagnoses, and _____.
goals and expected outcomes
Sometimes it is necessary to collect evaluative measures over time to determine whether a _____ exists when revising a care plan.
pattern of change
When revising a care plan make sure interventions are ______ based on the standard of care. Also, make sure the intervention is applied correctly.
appropriate
Remember a patient’s nursing diagnoses, _____, and interventions sometimes change as a result of evaluation.
priorities
Modify a care plan if the patients needs are ____.
unmet
When a goal is not met, repeat the entire nursing process ____ for that nursing diagnosis to identify necessary changes to the plan.
sequence
By consistently incorporating evaluation into practice, you ____ and ensure that the patient’s plan of care is appropriate and relevant.
minimize errors
Where/How does it fit in? How can I focus on these within the Nursing Process:
REVIEW
Where/How does it fit in? How can I focus on these within the Nursing Process:
Cultural (i.e. Asian, African, Hispanic)
Spiritual Considerations (i.e. Jewish, Jehovah Witness, Catholic)
Patient Education
Communication
Family & Patient
Healthcare Team
Diversity (i.e. LGBT, Geriatric, African American, Transgender)
Think ADPIE
Mass
Mcg –> mg
x1000
Mass
mg —> g
x1000
Mass
g —>kg
x1000
Volume
mL —->L
x1000
Time
Hr —> min
x60
Weight
Kg —> lb
(X2.2)
