The nursing process Flashcards
What are the 4 aspects of the nursing process?
systematic
rational
method of planning
Individualized
What are the 8 resources used for the nursing process in the UFV framework of caring?
1) critical thinking
2) standards
3) theory
4) research
5) nursing activities
6) experience
7) helping process
8) resource utilization
What are the things that should be assessed in addition to data from physical examination?
the individuals DOH
personal resources social resources professional resources environmental factors transitions
What is assessment?
collection and interpretation of clinical information/data
How would you go about assessing a person for the nursing process?
interview pt/family
head to toe assessment/focused assessment
consultation with health care team
medical records
What is data clustering?
grouping data together according to similarities
you do this in assessment
What is the most critical piece in the nursing process?
Assessment
What are the 6 steps of the nursing process?
1) Assessment
2) Nursing diagnosis
3) Planning
4) Implementation
5) Evaluation
6) Modification if necessary
What is a nursing diagnoses?
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)
What is very important to ensure when making a nursing diagnoses?
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
What is a medical diagnoses?
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)
Explain how a nursing diagnostic statement is structured for an actual problem
(actual problem) related to (cause or contributing factors) manifested by (signs and symptoms)
give an example of a nursing diagnoses for an actual problem.
impaired mobility r/t surgical pain m/b reluctance to get out of bed
How is a nursing diagnoses structured for a potential problem?
at risk for/of (problem) r/t (surgical pain)
ex
at risk for impaired mobility r/t surgical pain
there is no m/b
what are the 4 forms nursing diagnoses statements can take the form of?
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.
What happens in the planning phase of the nursing process?
1) priority setting
2) goal setting
3) developing a nursing care plan
What are goals?
statements of expected outcomes based on nursing diagnosis (problem statement)
What are the 5 characteristics that all nursing process goals must have.
T ime frame - will be... by.... R ealistic - A chievable M easureable P atient centered - the pt will...
What should goals focus on?
Nursing diagnoses; the identified problem
What happens during the implementation phase?
interventions based on PHC principles and partnerships
implement planned activities
ongoing ASSESSMENT of pt’s response
What are 3 things that interventions may involve?
1) assessment
2) nurse initiated activities (ex teaching, prevention, promotion)
3) physician initiated activities
What happens during the evaluation phase?
Assessment of goal achievement (goal partially met, met, not met))
if goal is not met review
diagnosis, goal, interventions
make revisions for modification
How does the nursing process “in action” differ from it in theory?
- 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
