Overview of The Nursing Process

Question 1

In 1958, she started the nursing process that still guides nursing care today.

Answer 1

Ida Jean Orlando

Question 2

A systematic, client-centered/person-centered method for structuring the delivery of nursing care.

Answer 2

Nursing Process

Question 3

1. Identify clients health status
2. To identify actual or potential health care problems or needs
3. To establish plans to meet identified needs
4. To deliver specific nursing interventions to meet identified needs

Answer 3

Purposes of the Nursing Process

Question 4

○ Assessment 
○ Diagnosis 
○ Planning 
○ Implementation 
○ Evaluation

Answer 4

Phases of the Nursing process (ADPIE)

Question 5

► Systematic & continuous collection, organization, validation, & documentation of data.
► A continuous process
► A wrong assessment can lead to a wrong diagnosis, planning, implementation, and evaluation.

Answer 5

Assessment

Question 6

1. Overlapping

2. Performed concurrently, at times

Answer 6

Characteristics of Good Health Assessment

Question 7

1. Collection of Subjective Data
2. Collection of Objective Data
3. Validation of Data
4. Documentation of Data

Answer 7

Steps of Health Assessment (CCVD)

Question 8

• Personal Information

- Feelings

Answer 8

Collection of Subjective Data

Question 9

• Sensations or symptoms
• Feelings
• Perceptions
• Preferences
• Beliefs
• Ideas
• Values
• Personal information

Answer 9

Other subjective data:

Question 10

A. Physical symptoms related to body parts
B. Past health history
C. Family history
D. Health and lifestyle practices

Answer 10

Major Areas of Subjective Data

Question 11

a) Physical characteristics
b) Body functions
c) Appearance
d) Behavior
e) Measurements
f) Results of laboratory testing

Answer 11

Collection of Objective Data

Question 12

► Ensures that the assessment process is not ended before all relevant data is collected.
► Ensures documentation of accurate data.

Answer 12

Validation of Data

Question 13

• Physical examination
• Review of patient’s charts
• Review of laboratory results
• Interview significant others and patient’s relatives

Answer 13

Some of the ways to validate data:

Question 14

► Provides data for all other members of the health care team.
► Must document all important data as it is used as a reference for the continuity of care.

Answer 14

Documentation of Data

Question 15

► Interpret assessment data

► Identify client strengths & problems

Answer 15

Diagnosing

Question 16

► Actual or potential health problem that independent / interdependent nursing interventions can prevent or resolve.
► Describes a continuum of health status; deviations from health, presence of risk factors and areas of enhanced personal growth.
► This will support the medical diagnosis of the physician.

Answer 16

Nursing Diagnosis

Question 17

Clusters of signs & symptoms that indicate the presence of a particular diagnostic label

Answer 17

Components of Nursing Diagnosis: Defining Characteristics

Question 18

1. Setting priorities
2. Establishing client goals
3. Selecting nursing interventions
4. Writing individualized nursing interventions on care plan

Answer 18

Planning Process (SESW)

Question 19

► Describes a change in the patient’s health status or functioning
► Expected outcome, predicted outcome, outcome criterion, objective

Answer 19

Establishing Goals

Question 20

S   –  Specific
M –  Measurable
A  –  Attainable
R  –   Realistic
T   –   Time bound

Answer 20

Guidelines for Writing Goals (SMART)

Question 21

Nursing functions without doctor’s order

Answer 21

Independent Nursing Interventions

Question 22

Needs doctor’s order, for example medication administration

Answer 22

Dependent Nursing Interventions

Question 23

► Crucial part of the nursing care process because your interventions must be precise. As much as possible, all interventions are for the recovery of the patient and not to cause harm.

► Activities the nurse plans and implements to help a patient achieve identified goal.

Answer 23

Nursing Interventions / Implementations

Question 24

1. PDx (Diagnostics)
2. PTx (Therapeutics)
3. PEd (Education or Health Teaching)

Answer 24

Components of the Nursing Interventions

Question 25

• Nursing interventions on the care plan should be: - Dated when they are written - Reviewed regularly at intervals • Dependent nursing interventions - Medication administration or anything that requires doctor's orders must be properly documented because it could be a basis for lawsuits or any medico legal cases.

Answer 25

Writing Individualized Nursing Interventions on Care Plan

Question 26

► Putting the nursing care plan into action to achieve the expected outcome. ► Involves: - Giving nursing care / carrying out the planned nursing activities - Delegating the care to another health care team member - Documenting and validating care - Continuing data collection

Answer 26

Implementation

Question 27

1. Doing 2. Delegating 3. Documenting

Answer 27

3 D's of Implementation

Question 28

``` · Care Aspect · Curative · Protective · Teaching · Patient Advocate ```

Answer 28

Aspects of a Nurse's Role (CCPTP)

Question 29

► Determining the client’s response to nursing interventions using the goals of care as criteria whether they were: met, partially met, and not met. ► All interventions (independent and dependent functions) should be effective.

Answer 29

Evaluation

Question 30

conclusion + supporting data

Answer 30

Evaluation Statement

Question 31

patient’s behavior + criteria of performance + time + conditions (if needed)

Answer 31

Goal Statement