The Nursing Process

Question 1

What is the nursing process?

Answer 1

• How we think
•How we determine what is happening
• How we plan care for patients
•How we evaluate if intervention was successful

Question 2

What are the 5 steps of the nursing process?

Answer 2

Assess
Diagnosis
Plan
Implementation
Evaluate

Question 3

Assess

Answer 3

Gather info
• What do I hear, see and know?
•Gather data- subj & obj
•Health history
• Questioning
•Observations
• Physical assessment

Question 4

Diagnose

Answer 4

Identify the patient’s
• Analyze assessment data
•Determine the nursing diagnosis
• Helps to plan nursing care

Question 5

What are the types of Nursing Diagnosis?

Answer 5

1- Actual: happening right now
• Impaired skin integrity
2- Risk: patient is vulnerable
• risk for impaired skin integrity
3- Health Promotion: Enhance health behaviors
• readiness for enhanced self care

Question 6

Components of a nursing diagnosis

Answer 6

1- Label: Patient’s response to a health problem
2- Related to: associated with patient’s actual problem or cause of the patient’s diagnosis

Question 7

Examples of nursing diagnosis

Answer 7

Problem related to Etiology

Question 8

What are the three parts of the nursing diagnosis?

Answer 8

Problem (NANDA list)
Etiology (related to)
Symptoms (as evidenced by….ex: pain when moving)

Question 9

Plan

Answer 9

Patient centered goal for nursing care
Collaborate with the patient and family, what are their goals?
What do you want to teach the patient?

Question 10

Patient goals

Answer 10

Precise
Observable
Measurable
Time limited
Mutual factors
Realistic

Question 11

Implementation of care- what are you going to do?

Answer 11

Independent nursing actions- no supervision from others
Dependent nursing interventions- require an order from HCP
Collaborative interventions- work with care team is the order appropriate?

Question 12

Implement the interventions?

Answer 12

Perform nursing care
Help patient achieve goals
Anticipate and prevent complications
Delegate appropriate actions
Educate the patient and family

Question 13

Evaluation

Answer 13

Did it work?
Did the patient get better? Did outcomes improve? Was your care effective? Requires reassessment and judgment!
If it didn’t work - revise plan of care!
Make changes based on the patient’s response.

Question 14

What’s a good analogy for the nursing process?

Answer 14

Nurse Detective-> problem solving & clinical decision making
• Based on the clues (assessment) Nursing knowledge (diagnosis) Nursing interventions (implementation) reflection (evaluation)