the nursing process

Question 1

what is the nursing process?

Answer 1

series of organized steps designed to provide excellent care, process with reason

Question 2

what are the 5 components to the nursing process? (think ADPIE)

Answer 2

1. assess
2. diagnose
3. plan
4. implement
5. evaluate

Question 3

what is part of the assess component of the nursing process?

Answer 3

gathering information about the client’s condition (subjective and objective)… relies on critical thinking skills… should be systematic and holistic… develop a base of data

Question 4

what are the different methods during the assessment phase?

Answer 4

labs, interview, observation, interpretation of the data

Question 5

what is primary data?

Answer 5

data directly from the pt

Question 6

what is secondary data?

Answer 6

data from all other sources than the pt

Question 7

who can provide secondary data?

Answer 7

family, healthcare team, medical records

Question 8

does subjective data have signs or symptoms?

Answer 8

symptoms

Question 9

does objective data have signs or symptoms?

Answer 9

signs

Question 10

what is a cue?

Answer 10

the information the nurse obtains through their senses

Question 11

what is an interence?

Answer 11

ones interpretation of the cues (what you think is happening)

Question 12

what is part of the diagnose component of the nursing process?

Answer 12

identifying the clients problems and considering how the client experiences their problems, NOT A MEDICAL DIAGNOSIS… knowing how the diagnosis affects the client

then generating a problem statement

Question 13

what is a problem statement derived from?

Answer 13

“whats going on with the pt”
derived during the assessment and reflecting on how the pt responds to the disease process

Question 14

what does identifying the problem mean? how does it differ from a medical diagnosis?

Answer 14

identifying the best way to help the pt and how you can contribute to their care, not a medical diagnosis bc it is not the disease, but how you can cater the care yo help the pt

Question 15

what is NANDA-I?

Answer 15

North American Nursing Diagnosis Organization International

Question 16

what does NANDA-I provide?

Answer 16

system used to state the priority problem with a pt, more than 200 diagnoses

Question 17

what are the 3 types of nursing diagnoses?

Answer 17

actual
risk statment
wellness

Question 18

what is the “actual” diagnosis?

Answer 18

identifies the problem happening with the pt

Question 19

what is the “potential risk” statement?

Answer 19

identifies something that puts the pt at higher risk due to their situation, hasnt occurred yet

Question 20

what is the “wellness” diagnosis?

Answer 20

identifies when things are going well with the pt, opportunity to enhance their wellness

Question 21

what is the priority problem?

Answer 21

the hypothesis, problem statement

Question 22

what is the primary diagnosis?

Answer 22

an issue that if not managed will deter progress and have negative outcomes with the pt

Question 23

what is a non-primary diagnosis?

Answer 23

treatment that can be delayed without compromising pt status

Question 24

least important
/ \
/ \ what is the ?
/ \
/ ? \ most important

Answer 24

physiological

Question 25

least important ?
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/ \
/ \
/ \ most important

Answer 25

self-actualization

Question 26

least important
/ ? \
/ \ what is the ?
/ \
/ \ most important

Answer 26

esteem

Question 27

least important
/ \
/ ? \ what is the ?
/ \
/ \ most important

Answer 27

love/belonging

Question 28

least important
/ \
/ \ what is the ?
/ ? \
/ \ most important

Answer 28

safety

Question 29

what are the 5 needs that are most important for pt care?

Answer 29

physiological, safety, love/belonging, esteem, self-actualization

Question 30

what is supportive data?

Answer 30

information that validates the problem statement/hypothesis… consists of evidence/assessment findings and contributing factors

Question 31

what is part of the plan component of the nursing process?

Answer 31

answers the question… “what are we going to do?”… sets goals for the pt

Question 32

what are the 3 components to the plan phase?

Answer 32

1. setting pt centred goals and objectives
2. determining the outcomes
3. setting appropriate nursing interventions

Question 33

what are the expected criteria for a plan?

Answer 33

SMART…
s - specific
m - measurable
a - attainable
r - relevant
t - time based

Question 34

what is part of the implement component of the nursing process?

Answer 34

performing nursing actions identified in the planning phase

Question 35

what are dependant nursing interventions?

Answer 35

require orders from a healthcare professional to implement

Question 36

what are independent nursing interventions?

Answer 36

no order is needed from another healthcare professional

Question 37

what are collaborative interventions?

Answer 37

require a combined knowledge, skill, and expertise from numerous healthcare providers

Question 38

what is part of the evaluate component of the nursing process?

Answer 38

determining if the goals were met and the outcomes acheived

Question 39

what are the 2 components of an evaluation?

Answer 39

an examination of a condition and judgment of the change has occured