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D2 > Nursing Process > Flashcards

Nursing Process Flashcards

1
Q

Nursing Process 5 Steps

A

-Assessment
-Nursing Diagnosis
-Planning
-Implementation
-Evaluation

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2
Q

What is the Nursing Process

A

-Series of organized steps designed to provide excellent care
-Intellectual process of reasoning
-Includes assessing, diagnosing, planning, implementing, and evaluating

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3
Q

What does the nursing practice do?

A

-Guides clinical judgement
-Decision making
-Reflective nursing practice
-Encourages critical thinking
-Not linear, steps continuously relate to each other

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4
Q

A-Assessment

A

Collection of data

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5
Q

D-Diagnosis

A

Diagnosis/Identify the problem, analyze data: makes decisions

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6
Q

P-Plan

A

Creation of formal plan/strategies

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7
Q

I-implementation

A

Care delivery

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8
Q

E-Evaluation

A

Clients responsiveness/effectiveness

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9
Q

Assessment Phase Methods of Data Collection

A

-Interpreting assessment data and making nursing judgements
-Physical examination
-Interviewing
-Observing client behaviour
-Diagnostic and lab data

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10
Q

Assessment Sources of Data: Primary

A

Patient/client

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11
Q

Assessment Phase Sources of Data: Secondary

A

-all sources other than the patient
-includes: family/support people, patient records, health care professionals

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12
Q

Subjective Data

A

-Patients perceptions or feelings
-Verbal data
-Symptoms

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13
Q

Objective Data

A

-What can be observed, perceives, and/or measured through the 5 senses or other instruments
-Non-verbal data
-Can be compared to a standard (BP, temp)
-Signs

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14
Q

Pt states they have chest pain

A

Symptom

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15
Q

Facial grimacing

A

Sign

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16
Q

BP 172/88

A

Sign

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17
Q

Reddened coccyx

A

Sign

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18
Q

Pain 6/10 written in chart

A

Symptom

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19
Q

Emaciated

A

Sign

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20
Q

Sad

A

Sign

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21
Q

What is a Cue

A

-Info the nurse obtains through use of the senses
-Info you perceive from the environment (subjective and objective data)

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22
Q

What is an Inference?

A

Ones judgement or interpretation of the cues

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23
Q

Cues vs Inference

A

Cue: Dry skin + reduced skin turgor
Inference: Dehydration
Cue: Incision hot, swollen, and reddened
Inference: Infected wound

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24
Q

Diagnosis =

A

Identify the clients problems
-Identify and prioritize the problem
-Clinical judgement
-Follows analysis of data
-Basis for interventions
-Which are most/least likely for THIS patient
-Which are most serious/dangerous/time sensitive

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25
Q

Identify the Problem =

A

-Not the same as a medical diagnosis
-Physicians licensed to treat diseases/pathological processes
-Use commonly accepted medical diagnosis to treat
-Nurses have a similar language = nursing diagnosis
-Determines health problems within domain of nursing

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26
Q

Nursing Diagnosis: NANDA

A

-Established in 1982
-Formerly the North American Nursing Diagnosis Organization
-Professional organization of nurses that standardize terminology for nursing process
-NANDA international Inc
-200 approved nursing diagnosis

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27
Q

Types of Nursing Diagnosis

A

Actual
Risk/potential
Wellness

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28
Q

Nursing Diagnosis: Actual

A

-Three part statements
-Represents a state that has been validated by major defining characteristics
-Actual problem, presence of major signs and symptoms

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29
Q

Example Actual Nursing Diagnosis

A

“Anxiety R/T asthmatic episodes AEB patient stating “I am afraid I won’t be able to breath”

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30
Q

Nursing Diagnosis: Risk (or high risk)

A

-Two part statement
-Represents a clinical judgement that the client is vulnerable to develop the problem/ a suspected problem, requires additional data
-Possible diagnosis
-No AEB because not actually occurring yet

31
Q

Examples Risk Nursing Diagnosis

A

-Risk for impaired skin integrity R/T immobility
-Possible self care deficit R/T impaired ability to use left hand due to IV

32
Q

Nursing Diagnosis: Wellness

A

-One part statement
-Represents the clients validated desire to move to a higher level of wellness
-Health promotion nursing diagnosis (related factors not present because all would be the same “motivated to achieve a higher level of wellness”

33
Q

Example Wellness Diagnosis

A

Readiness for enhanced …

34
Q

Medical or Nursing: Pt has LUL pneumonia

A

Medical

35
Q

M or D: Impaired gas exchange

A

Nursing

36
Q

M or N: Alteration in comfort

A

Nursing

37
Q

M or N: Enhanced coping skills

A

Nursing

38
Q

M or N: Stage 4 breast cancer

A

Medical

39
Q

M or N: Depression

A

Both (said N in class)

40
Q

M or N: Stage 1 Pressure Ulcer

A

Medical

41
Q

M or N: Impaired skin integrity

A

Nursing

42
Q

Examples of N and M diagnosis (both)

A

Anxiety
Hypothermia
Constipation

43
Q

Problem Statement vs Nursing Diagnosis

A

-Most important to choose the problem that best fits the data
-Don’t get stuck on the language
-If you are using “nursing diagnosis” it need to be stated correctly (3/2/1 part statement, NANDA dx)
-Neither are medical diagnosis
-Priority problem; Problem statement; Hypothesis

44
Q

How to chose the priority (priority diagnosis vs non-priority)

A

-Priority: Those nursing or collaborative problems that If not managed now will deter progress to achieve outcomes or will negatively affect client status
-Non-Priority: Those nursing or collaborative problems for which treatment can be delayed without compromising the client status

45
Q

Priority can..

A

Change within minutes

46
Q

Types of priority:

A

Priority diagnosis
Intermediate
Low priority

47
Q

Priority

A

If left untreated will result in harm to the patient (oxygenation, safety)

48
Q

Intermediate

A

Non emergency, non life threatening

49
Q

Low priority

A

Affect clients future well-being

50
Q

Priority Problem Statement

A

-What are the reasons why this problem might be happening?
-Do the assessment findings support this choice ?
-Why have you made this the priority?

51
Q

Prioritizing based on

A

-Based on hierarchy of needs
-Urgency or need for action
-What the client sees as a priority
-Time needed to resolve problem
-Availability of resources

52
Q

Problem Statement (what to do)

A

-Cluster the data
-What is not relevant?
-What else do you want to know?
-How could you get that info?
-What are the problems?
-What is the priority problem?
-What is the problem statement?

53
Q

Supportive Data

A

-Info that validates the problem statement/hypotheses and adds to the overall understanding of the patients situation
-Evidence/assessment findings
-Contributing factors

54
Q

Supportive data/problem case

A

Problem statement: Student late for AM classes
Evidence/Assessment Findings:
1) Student getting a zero on quizzes given at start of class because they miss the quiz
2) Student always seen frantically running through the hallway to get to classes in AM
3) Student frequently must sit on stairs of lecture theatre because no seats left
Contributing Factors:
1) Student needs coffee because only getting 3 hours of sleep a night

55
Q

Planning Phase 3 Components

A
  1. Set client cantered objectives/goals
  2. Determine expected outcomes
  3. Select appropriate nursing interventions
56
Q

Example Goal (Planning)

A

Student will be on time for class

57
Q

Planning Phase: SMART

A

S-Specific
M-Measurable
A-Attainable
R-Relevant
T-Time based

58
Q

Expected outcomes of planning

A

-Specific, measurable change in clients health status
-Physiological, psychological, social, developmental, spiritual
-Several expected outcomes for each goal
-Include time frames
-Measurable

59
Q

Examples Data Supporting Problem Statement & Expected Outcome Criteria

A

1) Nauseated for past 2 days
1) Client will report decreased nausea in 8 hours
2) Emesis x3
2) Client will retain clear fluid diet in 24 hours
3) Mucous membranes dry
3) Client will display moist mucus membranes in 24 hours
4) Unable to keep food or fluids down for past 24 hours
4) Client will have a balanced intake and output in 48 hours

60
Q

Implementation Phase: Nursing Intervention

A

-What are you going to do?
-“Implementing interventions” =carrying out the plan
-Preparation, control environment and practice safely
-Client needs
-Anticipating and preventing complications

61
Q

Independent Nursing Interventions

A

-No direction or orders from another health care professional required to implement

62
Q

Dependent Nursing Intervention

A

-Require orders or directions from a health care professional to implement (require independent judgement by the nurse)

63
Q

Collaborative Interventions

A

Require the combined knowledge, skill, and expertise of numerous health care providers

64
Q

Examples of Nursing Interventions

A

1) Assessment
2) Providing direct care
3) Assisting self care and ADL
4) Positioning
5) Dressings
6) Medications
7) Communicating
8) Lifesaving measures

65
Q

Rationale for interventions

A

Rationale: Are evidence based support for the nursing interventions
-Need rationale for each individual intervention

66
Q

Evaluation 2 components

A

1) An examination of a condition
2) Judgement as to whether change has occurred
-Ideally an intervention will lead to an improvement
-Reviews expected outcomes for client and judges whether or not successful

67
Q

Evolution

A

-Ongoing process whenever a nurse has contact with a patient
-Dynamic and ever-changing
-Make clinical decisions and redirect nursing care

68
Q

Positive Evaluations

A

Desired outcomes are met

69
Q

Unmet/undesirable outcomes

A

Interventions not effective

70
Q

Documenting Evaluations

A

-Continue the care plan: if the diagnosis is still present and the goals and interventions are still appropriate
-Modify/Revise: if the diagnosis is still present, but the goals or interventions require revision
-Achieved: the goals have been achieved and that portion of the care plan is discontinued

71
Q

Nursing Care Plans

A

Written documentation of the nursing process you use to solve one or more of a patients nursing problems

72
Q

Nursing Care Plan Purpose

A

-Provide the direction for the individualized care of the client
-Continuity of Care (communication, organization, constantly changing staff)
-Helps documentation

73
Q

What is the contributing factor

A

Factor maybe leading to or causing the problem

74
Q

What is supportive data

A

Additional info that validates the chosen nursing diagnosis/hypothesis/problem statement and adds to the overall understanding of the patients situation

D2 (4 decks)

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