Nursing Process

Question 1

A systematic, client-centered method for structuring the delivery of nursing care.

Answer 1

Nursing Process

Question 2

Nursing Process…
• Provides structure for __________

Answer 2

nursing practice

Question 3

Nursing Process…
• Entails gathering and analyzing __________

Answer 3

data

Question 4

Nursing Process…
• Helps enhance __________

Answer 4

critical thinking

Question 5

Nursing Process…
• __________ – central figure

Answer 5

Patients

Question 6

PURPOSES of the NURSING PROCESS
1. To identify client’s (1) __________
2. To identify actual or potential (2) __________ or __________

Answer 6

(1) health status
(2) health care problems or needs

Question 7

PURPOSES of the NURSING PROCESS
3. To establish plans to meet (1) __________
4. To deliver specific (2) __________ to meet identified needs

Answer 7

(1) identified needs
(2) nursing interventions

Question 8

Systematic & continuous collection, organization, validation, & documentation of data

Answer 8

Health Assessment

Question 9

Health Assessment is a __________

Answer 9

continuous process

Question 10

The focus of Health Assessment: __________

Answer 10

client’s health status

Question 11

Preparing for Assessment
•Organize (1) _______ and ________
•Organize your (1) __________
•Review (3) __________
•Keep an (4) __________ and avoid __________

Answer 11

(1) equipment and supplies
(2) thoughts
(3) medical record
(4) open mind / judgments

Question 12

STEPS OF HEALTH ASSESSMENT
• Collection of (1) _______ data
• Collection of (2) _______ data
• (3) _______ of data
• (4) _______ of data

Answer 12

(1) subjective
(2) objective
(3) Validation
(4) Documentation

Question 13

• Personal information
• Feelings

Answer 13

STEP 1: COLLECTION OF SUBJECTIVE DATA

Question 14

• Physical symptoms related to body parts
• Past health history
• Family history
• Health and lifestyle practices

Answer 14

MAJOR AREAS OF SUBJECTIVE DATA

Question 15

• Physical characteristics
• Body functions
• Appearance
• Behavior
• Measurements
• Results of laboratory testing

Answer 15

STEP 2: COLLECTION OF OBJECTIVE DATA

Question 16

• Ensures that the assessment process is not ended before all relevant data is collected
• Ensures documentation of accurate data

Answer 16

STEP 3: VALIDATION OF DATA

Question 17

• Provides data for all other members of the health care team

Answer 17

STEP 4: DOCUMENTATION OF DATA

Question 18

Characteristics of the STEPS:

• (1) __________
• Performed (2) __________, at times

Answer 18

(1) Overlapping
(2) concurrently

Question 19

So, thorough assessment can generate A LOT OF ________.

Answer 19

DATA

Question 20

• Interpret assessment data
• Identify client strengths & problems

Answer 20

DIAGNOSING

Question 21

Data Analysis
Problem Identification
Formulation of Nursing Diagnostic Statement

Answer 21

DIAGNOSING

Question 22

• Actual or potential health problem that independent / interdependent nursing interventions can prevent or resolve

Answer 22

Nursing Diagnosis

Question 23

Nursing Diagnosis
• Describes a (1) __________; deviations from health, presence of risk factors and areas of enhanced personal growth

Answer 23

(1) continuum of health status

Question 24

• What do you want to happen?
• How can you make it happen?

Answer 24

Planning

Question 25

Planning > Developing a (1) __________ > Nurse works with the client to (2) __________

Answer 25

(1) plan of care (2) set goals / outcomes

Question 26

Planning 1. Setting (1) __________ 2. Establishing (2) __________ 3. Selecting (3) __________ 4. Writing individualized (4) __________ on care plan

Answer 26

(1) priorities (2) client goals (3) nursing interventions (4) nursing interventions

Question 27

In Planning: 1. The most important (1) _______ to the patient 2. (2) _______ of potential problems 3. (3) _______, _______ available, _______, _______ needed

Answer 27

(1) problems (2) Effect (3) Costs / resources / personnel / time

Question 28

• Describes a change in the patient’s health status or functioning • Expected outcome, predicted outcome, outcome criterion, objective

Answer 28

Goal

Question 29

Situation: Frail elderly man with a pressure ulcer on his sacral area Type of Goal: The patient’s sacral area will exhibit no evidence of a pressure ulcer.

Answer 29

Long Term Goal

Question 30

Situation: Frail elderly man with a pressure ulcer on his sacral area Type of Goal: At the end of the first week, the patient’s pressure ulcer would have decreased in size by a quarter inch.

Answer 30

Short Term Goal

Question 31

Guidelines for Writing Goals S - _______ M - _______ A - _______ R - _______ T - _______

Answer 31

Specific Measurable Attainable Realistic Time-Bound

Question 32

Attribute of Goal: The patient will ambulate with assistance from bed to bathroom by tomorrow.

Answer 32

MEASURABLE GOALS

Question 33

Guidelines for Writing Goals The goal is (1) ________ with and (2) ________ of other therapies.

Answer 33

(1) congruent (2) supportive

Question 34

Guidelines for Writing Goals • Whenever possible, the goal is important and valued by (1) __________. • Derive each goal from only (2) __________. • Keep the goal (3) __________.

Answer 34

(1) the patient, the nurses, and the physician (2) one nursing diagnosis (3) short

Question 35

• Activities the nurse plans and implements to help a patient achieve identified goal

Answer 35

SELECTING NURSING INTERVENTIONS

Question 36

Components of Nursing Intervention

Answer 36

PDx - Diagnostics PTx - Therapeutic PEd - Education or Health Teaching

Question 37

(Diagnostics) ex: weighing, VS, Hgt monitoring

Answer 37

PDx

Question 38

(Therapeutic) ex: administering of Paracetamol 500 mg. 1 tab. q4H as ordered by the physician

Answer 38

PTx

Question 39

(Education or Health teaching) ex: Instruct the patient on proper wound dressing.

Answer 39

PEd

Question 40

Nursing interventions on the care plan should be: • (1) ________ when they are written • (2) ________ regularly at intervals

Answer 40

(1) Dated (2) Reviewed

Question 41

Implementation D - ________ D - ________ D - ________

Answer 41

Doing Delegating Documenting

Question 42

Putting the nursing care plan into action to achieve the expected outcome

Answer 42

Implementation

Question 43

Giving nursing care/carrying out the planned nursing activities

Answer 43

Implementation

Question 44

Delegating the care to another health care team member

Answer 44

Implementation

Question 45

Documenting and validating care Continuing data collection

Answer 45

Implementation

Question 46

Determining the client’s response to nursing interventions using the goals of care as criteria whether they were - Met - Partially Met - Not Met

Answer 46

Evaluation

Question 47

Goal Statement • Will ambulate half the length of hallway w/ assistance 3x daily Evaluative Statement • Goal is __________. Patient refused to ambulate in the morning but walked to the bathroom once in the afternoon w/ the assistance of one nurse.

Answer 47

Goal partially met

Question 48

Goal Statement • Body temperature will decrease from 38.50C to 36.50C - 37.50C within 2 hrs. after administering TSB. Evaluative Statement • Goal is ________. Body temperature went down to 37.20C within 2 hours after TSB administration.

Answer 48

Goal met