TEST 2 - UNIT B - CH 7 - NURSING PROCESS (Fundamentals Book) Flashcards
The nursing process is a
cyclical, critical thinking process
The nursing process of
five steps to follow in a purposeful, goal‑directed, systematic way to achieve
The nursing process - way to achieve
optimal client outcomes
The nursing process is a variation of
scientific reasoning that helps nurses organize nursing care and apply the optimal available evidence to care delivery.
The nursing process is a variation of
dynamic, continuous,
client‑centered, problem‑solving, and decision‑making framework that is foundational to nursing practice
The nursing process provides a framework throughout which
nurses can apply knowledge, experience, judgment, and skills, as well as established standards of nursing practice to the formulation of a plan of nursing care.
This nursing plan is applicable to any
client system, including individuals, families, groups, and communities.
The nursing process helps nurses integrate
critical thinking creatively to base nursing judgments on reason.
The nursing process promotes
the professionalism of nursing while differentiating the practice of nursing from the practice of medicine and that of other health care professionals.
● Assessment/data collection involves
the systematic collection of information about clients’ present health statuses to identify needs and additional data to collect based on findings. Nurses can collect data during an initial assessment (baseline data), focused assessment, and ongoing assessments.
● Methods of data collection include
observation, interviews with clients and families, medical history, comprehensive or focused physical examination, diagnostic and laboratory reports, and collaboration with other members of the health care team.
● To collect data effectively, nurses must
ask clients appropriate questions, listen carefully to responses, and have excellent head‑to‑toe physical assessment skills. Nurses also must employ clinical judgment and critical thinking in accurately recognizing when to collect assessment data. They also must recognize the need to collect assessment data prior to interventions.
● Nurses collect subjective data (manifestations) during a
nursing history. They include clients’ feelings, perceptions, and descriptions of health status. Clients are the only ones who can describe and verify their own manifestations.
● Nurses observe and measure
objective data (findings) during a physical examination. They feel, see, hear, and smell objective data through observation or physical assessment of the client. (7.2)
● During this assessment/data collection, the nurse
validates, interprets, and clusters data.
● Documentation of the assessment data must be
thorough, concise, and accurate.
Sources of data for collection and assessment
primary and secondary
primary sources can be
subjective / objective
secondary sources can be
subjective / objective
Primary sources
SUBJECTIVE:
SUBJECTIVE: What the client tells the nurse
“My shoulder is really, really sore.”
Primary sources
objective
OBJECTIVE: Data the nurse obtains through observation and examination:
Client grimaces when attempting to brush their hair with their left arm.
Secondary sources
SUBJECTIVE
● What others tell the nurse
● What the client has told them:
“They told me that their shoulder is sore every morning.”
Secondary sources
OBJECTIVE
Data the nurse collects from other sources (family, friends, caregivers, health care professionals, literature review, medical records):
Physical therapy note in chart indicates client has decreased range of motion of left shoulder.
The nursing process includes sequential but overlapping steps:
● Assessment/data collection*
● Analysis/data collection*
● Planning
● Implementation
● Evaluation
*PNs combine the assessment and analysis steps into
a single data collection step.
The accuracy and thoroughness of assessment/analysis/data collection and planning have a direct effect on
implementation and evaluation.
Use of the nursing process results in a
comprehensive, individualized, client‑centered plan of nursing care that nurses can deliver in a timely and reasonable manner.
● Nurses use *
critical thinking skills (a diagnostic reasoning process) to identify clients’ health statuses or problem(s), interpret or monitor the collected database, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care.
● Analysis/data collection requires nurses to look at the data and
Recognize patterns or trends.
◯ Compare the data with expected standards or reference ranges.
◯ Arrive at conclusions to guide nursing care.
● RNs make multiple analyses based on their
interpretations of collected data.
● As with the assessment/data collection step,
complete and accurate documentation is essential.
Nurses decide, using
reasoning and judgment, which data account for clients’ health status or problems.
At times, this requires further data collection and analysis. As nurses again cluster the collected data, a specific finding might serve as
an alert to a specific problem that requires planning and intervention.
Documentation should focus on
facts and should be highly descriptive.
● When planning client care (RN) or contributing to a client’s plan of care (PN), nurses must establish
priorities and optimal outcomes of care they can readily measure and evaluate.
These established priorities and outcomes of client care then direct nurses in
selecting interventions to include in a plan of care to promote, maintain, or restore health.
● Nurses do three types of planning.
Initially, they develop a comprehensive plan of care for clients based on comprehensive assessments they complete, for example, on admission to a health care facility or to a home health organization.
● Nurses do
ongoing planning throughout the provision of care.
While obtaining new information and evaluating responses to care, they
modify and individualize the initial plan of care.
● Discharge planning is a
process of anticipating and planning for clients’ needs after discharge.
To be effective, discharge planning must begin
during admission.
● Throughout the planning process, nurses set
priorities, determine client outcomes, and select specific nursing interventions.
● Nurses participate in priority setting when they
identify a preferential order of problems.
priority setting ( preferential order of problems) guides the
delivery of nursing care. They can use guidelines to set priorities (Maslow’s hierarchy of basic needs).
● Nurses work with clients to identify
goals and outcomes.
◯ Goals identify
optimal status, whereas outcomes identify the observable criterion that will determine success or failure of the goal.
goals and outcomes
terms are interchangeable.
With any format, the goal/outcome must be
client‑centered, singular, observable, measurable, time‑limited, mutually agreeable, and reasonable.
Concise, measurable goals help nurses and clients
evaluate progress:
◯ Nurses use
short‑ and long‑term goals to guide the client toward the planned outcome and determine the effectiveness of nursing care.
● Nurses identify
actions and interventions that help achieve optimal outcomes.
Scientific principles provide the
rationale for nursing interventions.
Nurses use
evidence and scientific rationale to take autonomous actions to benefit clients.
They base these actions on
identified problems and health care needs, and make sure they are within their scope of practice.
Nurses perform or delegate the interventions and are
accountable for them.
An example of delegation
is repositioning a client at least every 2 hr to prevent skin breakdown.
Provider‑initiated/dependent interventions:
Interventions nurses initiate as a result of a provider’s prescription (written, standing, or verbal) or the facility’s protocol (blood administration procedures).
◯ Collaborative interventions: *
Interventions nurses carry out in collaboration with other health care team professionals
EX of collaboration
(ensuring that a client receives and eats their evening snack).
● The nursing care plan (NCP) is the
end product of the planning step.
Nurses organize the NCP for*
quick identification of problems, outcomes, and interventions to implement.
IMPLEMENTATION
● In this step of the nursing process, nurses base the care they provide on assessment data, analyses, and the plan of care they developed in the previous steps of the nursing process
In the implementation step, the nurse must use
problem‑solving, clinical judgment, and critical thinking to
problem‑solving, clinical judgment, and critical thinking is used to
select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain, or restore health.
Nurses also use
interpersonal skills (therapeutic communication) and technical skills psychomotor performance) when implementing nursing interventions.
● Therapeutic interventions also include
measures nurses take to minimize risk (wearing personal protective equipment).
Nurses intervene to respond to
unplanned events (an observation of unsafe practice, a change in status, or the emergence of a life‑threatening situation).
● Nurses use
evidence‑based rationale for the selection and implementation of all therapeutic interventions.
Additionally,_______________should be at the center of all therapeutic nursing interventions.
caring and professional behavior
● During implementation, nurses perform
nursing actions, delegate tasks, supervise other health care staff, and document the care and clients’ responses.
Maslows heirarchy of needs
self actualization / self esteem / love and belonging / safety and security / physiological
EVALUATION
● In this step of the nursing process, nurses evaluate clients’ responses to nursing interventions and form a clinical judgment about the extent to which clients have met the goals and outcomes.
● Nurses continuously
evaluate clients’ progress toward outcomes,
use clients’ data to determine whether or not to modify the plan of care.
● Nurses determine the
effectiveness of the nursing care plan.
They collect data based on the
outcome criteria then compare what actually happened with the planned outcomes. This helps determine what further actions to take.
● Clients’ outcomes in________ __________ ___________ are easier to evaluate.
specific, measurable terms
QUESTIONS TO CONSIDER when deciding effecting of POC
● “Did the client meet the planned outcomes?”
● “Were the nursing interventions appropriate and effective?”
● “Should I modify the outcomes or interventions?”
FACTORS THAT CAN LEAD TO LACK OF GOAL ACHIEVEMENT
● An incomplete database
● Unrealistic client outcomes
● Nonspecific nursing interventions
● Inadequate time for the client to achieve the outcomes
- By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?
A. Reassess the client to determine the reasons for inadequate pain relief.
B. Wait to see whether the pain lessens during the next 24 hr.
C. Change the plan of care to provide different pain relief interventions.
D. Teach the client about the plan of care for managing the pain.
1.
A. CORRECT: Collect further data from the client to determine why they have not achieved satisfactory pain relief, because various factors might be interfering with their comfort. The nursing process repeats in an ongoing manner across the span of client care.
B. Do not wait longer to see how the client would respond, but take action to determine why the client is not achieving satisfactory pain relief.
C. Do not make random changes to the plan of care without gathering evidence to guide the nurse in knowing what new interventions might help.
D. The action does not acknowledge the client’s condition or that the current plan is ineffective.
- A charge nurse is observing a newly licensed nurse care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was 6 hr ago. The prescription reads every 4 hr PRN for pain. The nurse administered the medication and checked with the client 40 min later, when the client reported improvement. The newly licensed nurse left out which of the following steps of the nursing process?
A. Assessment
B. Planning
C. Intervention
D. Evaluation
- A. CORRECT: The newly licensed nurse should have used the assessment step of the nursing process by asking the client to evaluate the severity of pain on a 0 to 10 scale. The nurse also should have asked about the characteristics of the pain and assessed for any changes that might have contributed to worsening of the pain.
B. The newly licensed nurse used the planning step of the nursing process when deciding that it was the right time to administer the medication.
C. The newly licensed nurse used the implementation step of the nursing process when administering the medication.
D. The newly licensed nurse used the evaluation step of the nursing process when checking the effectiveness of the pain medication in relieving the client’s pain.
- A charge nurse is reviewing the steps of the nursing process with a group of nurses. Which of the following data should the charge nurse identify as objective data? (Select all that apply.)
A. Respiratory rate is 22/min w/ even, unlabored respirations.
B. The client’s partner states, “They said they hurt after walking about 10 minutes.”
C. The client’s pain rating is 3 on a scale of 0 to 10.
D. The client’s skin is pink, warm, and dry.
E. The assistive personnel reports that the client walked with a limp.
- A. CORRECT: Objective data includes information the nurse measures (vital signs).
B. Subjective data includes a client’s reported manifestations, even if a secondary source gave the nurse the information.
C. Subjective data includes a client’s reported manifestations.
D. CORRECT: Objective data includes information the nurse observes (skin appearance).
E. CORRECT: Objective data includes information from the observations of others (family and staff).
- A charge nurse is talking with a newly licensed nurse and is reviewing nursing interventions that do not require a provider’s prescription. Which of the following interventions should the charge nurse include? (Select all that apply.)
A. Writing a prescription for morphine sulfate as needed for pain
B. Inserting a nasogastric (NG) tube to relieve gastric distention
C. Showing a client how to use progressive muscle relaxation
D. Performing a daily bath after the evening meal
E. Repositioning a client every 2 hr to reduce pressure injury risk
- A. Have a prescription from the provider to administer a medication. After obtaining the prescription, the nurse has the flexibility to determine when to administer a PRN medication.
B. Have a prescription from the provider for the insertion of an NG tube. This is a provider‑initiated intervention.
C. CORRECT: Showing a client how to use progressive muscle relaxation is an appropriate nurse‑initiated intervention for stress relief. Unless there - contraindication for a specific client, use this technique with clients without a provider’s prescription.
D. CORRECT: Performing a bath is a routine nursing care procedure. Unless there is a contraindication for a specific client, determine when bathing is optimal for a client without a provider’s prescription.
E. CORRECT: Repositioning a client every 2 hr is an appropriate nurse‑initiated intervention for clients. Unless there is a contraindication for a specific client, use this strategy without a provider’s prescription.
- A nurse is discussing the nursing process w/ a newly licensed nurse. Which of the following statements by the newly licensed nurse should the nurse identify as appropriate for the planning step of the nursing process?
A. “I will determine the most important client problems that we should address.”
B. “I will review the past medical history on the
client’s record to get more information.”
C. “I will carry out the new prescriptions from the provider.”
D. “I will ask the client if their nausea has resolved.”
- A. CORRECT: Prioritize the client’s problems during the planning step of the nursing process.
B. Review the client’s history during the assessment/data collection step of the nursing process.
C. Implement nurse‑ and provider‑initiated actions during the intervention step of the nursing process.
D. Gather information about whether the client’s problems have been resolved during the evaluation step of the nursing process.
● List at three actions to take during the analysis or data collection step.
● Recognize patterns or trends.
● Compare the data with expected standards or reference ranges.
● Arrive at conclusions to guide nursing care.
● List four factors to consider during the evaluation step when clients have not achieved their goals.
● An incomplete database
● Unrealistic client outcomes
● Nonspecific nursing interventions
● Inadequate time for the client to achieve the outcomes
