The Nursing Process

Question 1

What are the steps of the nursing process?

Answer 1

*Assessment
*Nursing diagnosis
*Planning
*Interventions/implementation
*Evaluation

Question 2

What is the difference between a medical diagnosis and nursing diagnosis

Answer 2

Medical diagnosis: Focuses more on the psychological event or disease (e.g… pneumonia)
Nursing Diagnosis: Focuses more on the patient is reinserted to a health problem (e.g… reduced breathing pattern)

Question 3

Whta are the sources of data in the assessment phase?

Answer 3

Primary:From the pt
Secondary:From family,health records or other health professionals
Tertiary: Relevant to literature or the nurse is experience

Question 4

What is the difference between objective and subjective date?

Answer 4

Objective: is anything that is observable or measured (vitals signs)
Subjective: anything the pt tells you (complaints or symptoms)

Question 5

What is the SMART approach to setting nursing goals

Answer 5

Specific
Measurable
Achievement
Reasonable/Relevant
Time-limited

Question 6

What are the types of nursing interventions?

Answer 6

*Nurse initiated =independent actions (e.g…elevating extremity)
*Physician initiated =dependant actions that require physician orders (e.g…administering medications)
*Collaborative =Combined actions fro various healthcare providers (e.g…physical therapy)

Question 7

What should you assess in the evaluation phase of the nursing process?

Answer 7

Whether the expected outcomes or goals have been met if not re-assess the process for any missed findings or new actions to take.

Question 8

What is the nursing process important?

Answer 8

It provides a structured framework to identify,prioritize and address pt is needs

Question 9

What is the purpose of the assessment phase?

Answer 9

To gather info on pt to identify they needs and potential problems

Question 10

What methods are used to collect assessment data?

Answer 10

*interviews
*Nursing health history
*Physical exams
*Review of lab/test results

Question 11

What are the components of a nursing diagnosis?

Answer 11

PES
Problem (the issue)
Etiology (cause or related factor)
Signs and symptoms (evidence)

Question 12

Give an example of a nursing diagnosis?
A pt is immobile because they recently in a really bad car accident so they need help repositioning.

Answer 12

Impaired bed mobility related to car accident as evidenced by inability to reposition self in bed

Question 13

What is the goal of the planning phase?

Answer 13

To establish measurable and achievable short or long term goals for the pt.

Question 14

Why is prioritization important in planning?

Answer 14

To address the most urgent problems first (e.g… Maslow is hierarchy of needs)

Question 15

What is the focus of the implementation phase in the nursing process?

Answer 15

to achieve the pt is goal

Question 16

What is the difference between direct and indirect care?

Answer 16

Direct care =interventions w pt contact (e.g… dressing changes)
Indirect care =Actions performed away from the pt (e.g…infection control or documentation)

Question 17

What is the main goal of evaluation in the nursing process?

Answer 17

To determine if the pt is goals were met and if interventions were effective.