Nursing Process Flashcards
What are three benefits of the nursing process?*
- Assists nurses to provide quality care by applying a systematic process that fosters critical thinking and optimizes client care outcomes
- Helps organize and prioritize nursing care
- Allows nurse to provide multiple aspects of care simultaneously
What are the five steps of the nursing process ?*
- Assessment
- Diagnosis
- Planning
- Implementation
- Evaluation
Define the assessment stage of the nursing process?*
Collect data about the patient
How can data be collected throughout the assessment stage?*
The patient, physical examination and interview, diagnostics, other health care professionals, current/past medical records
What is the difference between signs and symptoms?*
Signs - objective assessments; what the nurse can see, feel, smell, and hear
Symptoms - subjective sensations; reports from clients (i.e., my heart is racing)
What are the differences between medical and nursing diagnoses? Provide an example of each*
Medical diagnosis
- relates primarily to the disease process, pathology, and/or condition
- tends to remain static during episode of illness
- Ex. COVID pneumonia
Nursing diagnosis
- relates to the client’s response to or experience of actual or potential health conditions and/or life processes
- can change throughout the illness or disease experience
- Ex. difficulty breathing; inadequate gas exchange
Describe the planning stage of the nursing process*
Involves the client to determine goals - priorities may change as the client’s condition changes
However, priorities must be determined before goals are established
Priority is based on the urgency of care deemed from the CURE approach
Describe the CURE approach*
Informs priorities based on status
Critical - something that will harm or end life in a short period of time (i.e., not breathing)
Urgent - an important need that may affect outcomes, but may be able to wait (i.e., pain needs to be managed)
Routine - things done for every patient (i.e., hygiene, assessments, weight)
Extra - Additional tasks, if time permits; only if the above three have been addressed (i.e., shave, take them outside)
What are the three different types of planning?*
- Initial - when they come in, what are their initial problems
- On-going - how do their care, goals, etc. change as they continue through admission (i.e., pneumonia patient’s oxygen needs may have decreased over time OR they develop a new complication)
- Discharge planning - what do they need to go home to maintain, continue to improve, recover, etc.?
Describe the implementation stage of the nursing process*
The nurse carries out and documents the interventions needed to achieve the client’s health-related goals
The interventions must match the goal
Describe the evaluation stage of the nursing process*
Collect data related to outcomes and document, draw conclusions about problem status, and continue, modify or end the client’s care plan
Have the goals been met?
May need to supervise or seek report on how the patient is doing/how interventions are working