The nursing process

Question 1

list key steps in the nursing process

Answer 1

Assessment 
(Nursing) Diagnosis 
Planning 
Implementation 
Evaluation

Question 2

give an example of assessment

why is assessment the first step in the process

Answer 2

doing a skin assessment, neural assessment, a psychological assessment, a physical (head to toe) a general assessment, etc.

WHY???
looking for deficits in self care (if going by Orem’s theory) and looking to establish a patient’s baseline

Question 3

give an example of a a nursing diagnosis

WHY?

Answer 3

a nursing diagnosis would be
ineffective airway clearance related to asthma as evidenced by SOB, wheezing and etc.

we diagnose so we can better understand what the problem is with our patient and then implement interventions to bring the patient back to a baseline level of functioning

A nursing diagnosis is NOT a medical diagnosis

Question 4

how do you write a nursing diagnosis?

Answer 4

1. qualifiers/focus “Acute pain”–acute is qualifier, pain is focus
2. “related too”
3. etiology/related factors “tissue ischemia”
4. As evidenced by
5. defining characteristics and risk factors “pain rated 8/10, grimacing, guarding behavior”

“Acute pain related to tissue ischemia as evidenced by pain rated 8/10, grimacing, and guarding behavior

Question 5

What is planning in the nursing process?
WHY is it important?
example

Answer 5

planning in the nursing process is deciding what interventions to employ, discontinue, enhance or weaken to promote patient independence, self-efficacy, safety and comfort.

Planning is important because it helps the nurse think critically about what the needs of the patient are.

an example of planning would be:
“pt. is going to ambulate to the end of the hallway 2X/day with walker and one assist”

Question 6

What is implementing in the nursing process?
WHY is it important?
Example

Answer 6

implementing in the nursing process is actually putting the plans you made from the planning stage into practice/action

implementing is important because you need to actually implement interventions if you want your patient to get better.

an example of implementing would be instructing the CNAs to walk the patient 2X/day and seeing that the patient is walked.

Question 7

what is evaluating in the nursing process
WHY is it important?
example

Answer 7

evaluating in the nursing process is where the nurse assesses the outcome of the implemented interventions in the patient care plan, wether they were benefical or not, if something needs to be changed or dc’d, etc.

evaluating is important because it helps the nurse determine the effectiveness of the interventions and gives them insight into how the patient is doing with the interventions.

example: nurse evaluating patient’s walking program. Can the patient tolerate walking 2X/day? If not, modify intervention. If yes, see if 3X a day could happen

Question 8

1 kilogram is how many lbs?

Answer 8

2.2 lbs

Question 9

1 cm is how many inches?

Answer 9

2.54 cm