Lecture 6 - The Nursing Process

Question 1

What are the two professional nursing organizations in Canada?

Answer 1

–> Canadian Nurses Association (CNA)
–> Canadian Nurses Protective Society (CNPS)

Question 1

What is the role of professional nursing organizations in Canada?

Answer 1

To serve as official representative of the nursing profession and interact with government officials on issues concerning the health of a population.

Question 2

What is the professional regulatory body for Canadian nurses?

Answer 2

College of Nurses of Ontario (CNO)

Question 3

Which professional union exists for all Canadian nurses?

Answer 3

Canadian Nurses Association (CNA)

Question 4

What is critical thinking?

Answer 4

A process and set of skills, includes the use of knowledge and reasoning to make accurate clinical judgements and decisions.

Question 5

What are the steps of a critical thinking process?

Answer 5

–> Recognizing the client’s health problem or concern
–> Analyze data
–> Review assumptions and evidence
–> Explore alternative solutions and prioritize the client’s preferences
–> Consider ethical principles
–> Draw conclusions on how to proceed

Question 6

What is basic critical thinking?

Answer 6

–> Thinking is concrete and based on a set of rules or principles
–> Rigid, black and white thinking with little flexibility for patient preferences or comfort

Question 7

What is complex critical thinking?

Answer 7

–> Begin to separate one’s own thinking from those of other experts
–> Realize that alternative and conflicting solution to a problem can exist - one must weigh the benefits and risk.

Question 8

What is the commitment level of critical thinking?

Answer 8

When one anticipates the need to make choices without assistance from other professionals, then assumes responsibility and accountability to those choices.

Question 9

What are the five components of critical thinking?

Answer 9

–> Specific Knowledge base
–> Experience
–> Competencies
–> Attitudes
–> Standards

Question 10

The analysis of data, the diagnosis, etiologies, current plans, and implemented interventions are part of which step in the nursing process?

Answer 10

Evaluation

Question 11

Data analysis, problem identification, and label are part of which step in the nursing process?

Answer 11

Diagnosis

Question 12

Priority and goal setting is part of which step in the nursing process?

Answer 12

Planning

Question 13

Nurse-initiated and physician initiated treatments are part of which step in the nursing process?

Answer 13

Implementation/intervention

Question 14

Subjective and objective data are part of which step in the nursing process?

Answer 14

Assessment

Question 15

What is nursing assessment?

Answer 15

The systematic and deliberate collection of data to determine a client’s current and past health status and functional status to determine the client’s present and past coping patterns.

Question 16

What are primary sources of information?

Answer 16

The client

Question 17

What are secondary sources of information?

Answer 17

–> Family and significant others
–> Health care team
–> Medical records

Question 18

What are tertiary sources of information?

Answer 18

–> Literature
–> Nurse’s experience

Question 19

What is the first step in a nursing assessment?

Answer 19

The Interview
–> Introduce oneself, and explain role as HCP
–> Establish therapeutic relationship
–> Obtain Insight about client’s concerns or worries
–> Determine the client’s goals and expectations
–> Obtain cues about what may require furthur assessment

Question 20

What is the second step in a nursing assessment?

Answer 20

Collecting Health History
–> Bio
–> AMPLE
–> Psychological, spiritual, sociocultural, developmental variables
–> Current state of health and reason for interview

Question 21

What is the third step in nursing assessment?

Answer 21

Physical Assessment

Question 22

What is done during data analysis and interpretation?

Answer 22

Data validation and recognition of patterns and trends.
Comparing with normal trends is also helpful.
All of this is needed for appropriate clinical decision making

Question 23

What is the purpose of a nursing diagnosis?

Answer 23

To determine the client’s health problems that are within the domain of nursing, in order to decide what care the client should receive

Question 24

What is the difference between a medical and nursing diagnosis?

Answer 24

A medical diagnosis is the identification of a disease condition based on specific evaluation of signs and symptoms A nursing diagnosis is a clinical judgement about a client's response to an actual or potential health problem

Question 25

What is a collaborative problem?

Answer 25

An actual or potential complication that nurses monitor to detect a change in the client status

Question 26

What is NANDA? What is their mission?

Answer 26

North American Nursing Diagnosis Association --> Mission is to facilitate the development, refinement, dissemination, and use of the standardized nursing terminology

Question 27

What is NANDA's purpose?

Answer 27

--> TO determine precise definitions and a common language among the profession --> To allow for clear communication --> To distinguish the nurse's role

Question 28

What is an Actual Nursing Diagnosis?

Answer 28

One that describes responses to health conditions or life processes that exist in an individual, family, or community

Question 29

What is a Risk Nursing Diagnosis?

Answer 29

One that describes responses to health conditions of life processes that may develop.

Question 30

What is a Health Promotion Nursing Diagnosis?

Answer 30

A clinical judgement of a person's family's or community's motivation and desire to increase well-being by readiness to enhance specific health behaviours, such as nutrition and exercise

Question 31

What is a Wellness Nursing DIagnosis?

Answer 31

One that describes the levels of wellness in an individual, family, or community that can be enhanced.

Question 32

What is the difference between a health promotion nursing diagnosis and a wellness nursing diagnosis?

Answer 32

A wellness nursing diagnosis describes wellness that can be enhanced, whereas a health promotion diagnosis can be used in any state and no not necessarily reflect current levels of wellness.

Question 33

The following statement is an example of which kind of nursing diagnosis? Risk for infection related to a site for organism invasion secondary to surgery

Answer 33

Risk Nursing Diagnosis

Question 33

What are the three components of an Actual Nursing Diagnosis?

Answer 33

Problem --> From NANDA-I list) Etiology -->Related cause or contributor to the problem Symptoms --> As described by patient [Diagnosis label] related to [Etiology] as evidences by [symptoms]

Question 33

What are the two components of a Risk Nursing Diagnosis?

Answer 33

Diagnosis --> Taken from official NANDA=I list Related Factors --> Risk factors [Diagnosis Label] related to [Risk factor]

Question 33

The following statement is an example of which kind of nursing diagnosis: Acute pain related to stress on surgical area during movement as evidences by patient report, elevated heart rate, and BP

Answer 33

Actual Nursing Diagnosis

Question 34

What is the only component of a health promotion or wellness nursing diagnosis?

Answer 34

The official label from NANDA-I list

Question 35

The following statement is an example of which kind of nursing diagnosis: Readiness for enhanced self-care

Answer 35

Health Promotion / Wellness

Question 36

What is the difference between a goal and expected outcome?

Answer 36

A goal represents the predicted resolution of nursing diagnosis or health problem, whereas expected outcome is the measurable criteria to evaluate goal achievement. These may be combined

Question 37

What are the the three types of interventions?

Answer 37

Independent --> Nurse initiated Dependent --> Physician initiated Collaborative --> Interdependent

Question 38

Which six factors must be considered when selecting interventions?

Answer 38

1. The nursing diagnosis 2. Expected outcomes 3. Evidence base for interventions 4. Feasibility of the intervention 5. Acceptability to the client 6. Nurse's competency

Question 39

Who developed the Nursing Interventions Classification (NIC)?

Answer 39

The Iowa Intervention Project

Question 40

What are four important components of the implementation step of the nursing process?

Answer 40

--> Reassessing the client --> Reviewing and revising existing nursing care plan --> Organizing resources and care delivery --> Anticipating and preventing complications

Question 41

What is indirect care? What are some examples?

Answer 41

Indirect care are actions that support the effectiveness of direct care intervention, such as: --> Communicating nursing interventions --> Documentation --> Medical order transcription --> Infection control --> Computer data entry -->Delegation, supervision, and evaluation of the work of staff members

Question 42

What are the five elements of evaluation in nursing care?

Answer 42

1. Identify evaluative criteria and standards 2. Collect evaluate data 3. Interpret and summarize findings 4. Document findings and clinical judgements 5. Terminate, continue, or revise the care plan.