Lesson 3 - The Nursing Process

Question 1

The Nursing Process

Answer 1

-ongoing (cyclical) process used with every patient interaction

Question 2

Nursing Process Characteristics

Answer 2

-client-centered
-focuses on problem solving and decision making
-collaborative
-uses critical thinking

Question 3

Purpose of the Nursing Process

Answer 3

-gather data (ie. by interview, chart, environment)
-cluster data (ie. by body system or hierarchy of needs)
-engage in critical thinking and clinical reasoning
-make decisions
-plan and evaluate care

Question 4

Step 1: Assessment

Answer 4

-collect, organize, validate, document data
-results in comprehensive understanding of patient situation
-holistic: past and present health status

Question 5

Initial Assessment

Answer 5

-explores presenting problem and contributing factors
-physical assessment
-health history
-psychosocial assessments

Question 6

Focused Assessment

Answer 6

-gathers specific details about presenting concern
-confirms or rules out abnormalities

Question 7

Time-lapsed Assessment

Answer 7

-reevaluate status
-has condition improved, worsened, or remained?

Question 8

Emergency Assessment

Answer 8

-ensure ABCs (airway, breathing, circulation)
-identify primary cause of problem

Question 9

Expected Findings Before Nursing School

Answer 9

-world view
-previous experiences
-culture, religion, family, friends
-K-12 knowledge

Question 10

Expected Findings During/After Nursing School

Answer 10

-understanding other perspectives
-school and clinical experiences
-cultural humility
-interpersonal relationship knowledge
-nursing knowledge

Question 11

Step 2: Nursing Diagnosis

Answer 11

-analyze data (significant vs. insignificant)
-identify problems, risks, strengths
-formulate diagnostic statements
-expected vs. unexpected findings

Question 12

Step 3: Planning

Answer 12

-prioritize (Mazlows Hierarchy of Needs)
-goals/desired outcomes
-identify nursing interventions

Question 13

Step 4: Implementation

Answer 13

-reassess patient
-determine need for assistance
-implement nursing interventions
-ensure interventions are in scope of practice
-document what you have done
-maintain safety
-teaching

Question 14

Step 5: Evaluation

Answer 14

-collect outcome related data
-draw conclusions
-continue, modify, or end care plan

Question 15

Interprofessional Teams (data sources)

Answer 15

-physicians (+ their notes)
-dietician
-PT
-OT
-spiritual caregiver
-social worker

Question 16

Medical Record/Chart

Answer 16

-holds various info in the form of a patient “file”
-nursing documentation, medical records, progress notes, test/lab results, interdisciplinary team notes

Question 17

Other sources of data

Answer 17

-books
-physical assessment
-patient and family

Question 18

Health Interview

Answer 18

-opportunity for nurse and patient to exchange information and form a therapeutic relationship
-doesn’t always have to be formal
-trust, respect, genuine

Question 19

Health Interview: Verbal Communication

Answer 19

-open + closed ended questions
-leading + neutral questions
-paraphrasing
-clarification

Question 20

Health Interview: Nonverbal Communication

Answer 20

-facial expressions
-gestures
-posture
-attentiveness

Question 21

Social Determinants of Health

Answer 21

-provide important context to life situations, health, relationships, outcomes, risks

Question 22

Sight (Assessment Tool)

Answer 22

-skin tone/bruises
-abnormal movements
-consciousness level
-response to touch

Question 23

Smell (Assessment Tool)

Answer 23

-unique smells

Question 24

Touch (Assessment Tool)

Answer 24

-skin temp
-fluid volume (edema)

Question 25

Sound (Assessment Tool)

Answer 25

-verbal -body processes

Question 26

Primary Data Sources

Answer 26

-patient

Question 27

Secondary Data Sources

Answer 27

-family & friends -environment -records -interprofessional team -literature

Question 28

Subjective Data

Answer 28

-based on feelings, opinions

Question 29

Objective Data

Answer 29

-factual, measurable -not based on opinion

Question 30

Inference

Answer 30

-conclusion reached from evidence and reasoning -confirm with patient -look at other data to validate

Question 31

Gordon's Functional Health Patterns

Answer 31

-used to gather patient info and sort the data into categories -ie. elimination, nutrition-metabolic, sleep-rest, role-relationship, etc.

Question 32

Maslow's Hierarchy of Needs

Answer 32

-from bottom (physiological needs) to top (self-actualization)

Question 33

Physiological Needs (bottom)

Answer 33

-breathing, food, water, excretion

Question 34

Safety

Answer 34

-security of body, employment, health, property

Question 35

Love/belonging

Answer 35

-family and friends -intimacy

Question 36

Esteem

Answer 36

-confidence, respect, achievement

Question 37

Self-actualization (top)

Answer 37

-morality -creativity -lack of prejudice

Question 38

Nursing Diagnosis

Answer 38

-focus on human response to actual or potential health problems/quality of life -within scope of practice

Question 39

Medical Diagnosis

Answer 39

-focus on illness/medical problem

Question 40

NANDA-I

Answer 40

-North American Nursing Diagnosis Association - International -13 categories -ie. nutrition, activity and rest, comfort, etc. -use nursing diagnosis handbook

Question 41

Steps to formulate Nursing Diagnosis

Answer 41

1. Choose a NANDA-I label (actual/risk/wellness/syndrome) 2. determine etiology (likely cause) of problem 3. List manifestations (signs and symptoms) - not for RISK!

Question 42

Initial Planning

Answer 42

-based on admission assessment -directs patient care

Question 43

Ongoing Planning

Answer 43

-continually changing plans based on response to care -based on assessment and evaluation

Question 44

Discharge Planning

Answer 44

-anticipate and plan for care needs when patient moves home or to another facility

Question 45

Goals/Outcomes

Answer 45

-broad statements -relate to nursing diagnosis

Question 46

SMART Goals

Answer 46

-specific -measurable -achievable -relevant -timely

Question 47

Independent Nursing Intervention

Answer 47

-nurse can accomplish without order from doc or np

Question 48

Dependent Nursing Intervention

Answer 48

-based on doc orders

Question 49

Collaborative Nursing Intervention

Answer 49

-nurse + another professional work together

Question 50

Direct Care

Answer 50

-involves working directly with the patient

Question 51

Indirect Care

Answer 51

-communicating with other HCPs about care -delegate, supervise, evaluate others work -plan and document care