The nursing process

Question 1

What are the 4 aspects of the nursing process?

Answer 1

systematic

rational

method of planning

Individualized

Question 2

What are the 8 resources used for the nursing process in the UFV framework of caring?

Answer 2

1) critical thinking
2) standards
3) theory
4) research
5) nursing activities
6) experience
7) helping process
8) resource utilization

Question 3

What are the things that should be assessed in addition to data from physical examination?

Answer 3

the individuals DOH

personal resources
social resources
professional resources
environmental factors
transitions

Question 4

What is assessment?

Answer 4

collection and interpretation of clinical information/data

Question 5

How would you go about assessing a person for the nursing process?

Answer 5

interview pt/family

head to toe assessment/focused assessment

consultation with health care team

medical records

Question 6

What is data clustering?

Answer 6

grouping data together according to similarities

you do this in assessment

Question 7

What is the most critical piece in the nursing process?

Answer 7

Assessment

Question 8

What are the 6 steps of the nursing process?

Answer 8

1) Assessment
2) Nursing diagnosis
3) Planning
4) Implementation
5) Evaluation
6) Modification if necessary

Question 9

What is a nursing diagnoses?

Answer 9

a clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that is within the domain of nursing (NANDA 2007)

Question 10

What is very important to ensure when making a nursing diagnoses?

Answer 10

that it is a nursing diagnoses not a medical diagnoses

ex. broken arm is causing pain, but broken arm can’t be fixed by nurse it is medical. So the problem here is the pain

Question 11

What is a medical diagnoses?

Answer 11

it is the identification of a disease condition on the basis of a specific evaluation of physical signs, symptoms, the client’s medical history, and the results of diagnostic tests and procedures (P&P)

Question 12

Explain how a nursing diagnostic statement is structured for an actual problem

Answer 12

(actual problem) related to (cause or contributing factors) manifested by (signs and symptoms)

Question 13

give an example of a nursing diagnoses for an actual problem.

Answer 13

impaired mobility r/t surgical pain m/b reluctance to get out of bed

Question 14

How is a nursing diagnoses structured for a potential problem?

Answer 14

at risk for/of (problem) r/t (surgical pain)

ex
at risk for impaired mobility r/t surgical pain

there is no m/b

Question 15

what are the 4 forms nursing diagnoses statements can take the form of?

Answer 15

1) one part statement/wellness nursing diagnoses
- readiness for enhanced parenting
- readiness for enhanced nutrition

2) 2 part statement/risk nursing diagnoses
- risk for injury r/t lack of awareness of hazards

3) 3 part statement/actual nursing diagnoses
- problem r/t cause m/b signs/symptoms

4) Unknown etiology
- fear r/t unknown etiology m/b rapid speech, stating “i’m worried.

Question 16

What happens in the planning phase of the nursing process?

Answer 16

1) priority setting
2) goal setting
3) developing a nursing care plan

Question 17

What are goals?

Answer 17

statements of expected outcomes based on nursing diagnosis (problem statement)

Question 18

What are the 5 characteristics that all nursing process goals must have.

Answer 18

T ime frame - will be... by....
R ealistic -
A chievable
M easureable
P atient centered - the pt will...

Question 19

What should goals focus on?

Answer 19

Nursing diagnoses; the identified problem

Question 20

What happens during the implementation phase?

Answer 20

interventions based on PHC principles and partnerships

implement planned activities

ongoing ASSESSMENT of pt’s response

Question 21

What are 3 things that interventions may involve?

Answer 21

1) assessment
2) nurse initiated activities (ex teaching, prevention, promotion)
3) physician initiated activities

Question 22

What happens during the evaluation phase?

Answer 22

Assessment of goal achievement (goal partially met, met, not met))

if goal is not met review
diagnosis, goal, interventions

make revisions for modification

Question 23

How does the nursing process “in action” differ from it in theory?

Answer 23

• less time for planning and reflection
• more interactive process with the pt
• observe immediate outcome of interventions
• move back and forth between steps in the process