Nursing Process

Question 1

Steps of the nursing process

Answer 1

Assessing
Diagnosing
Planning
Implementing
Evaluating

Question 2

What is assessing?

Answer 2

Collecting, validating, and communicating patient data

Question 3

What is diagnosing?

Answer 3

Analyzing patient data to identify patient strengths and problems

Question 4

What is planning?

Answer 4

Specifying patient outcomes and related nursing interventions

Establish priorities

We figure out our goals and come up with a plan to meet those goals!

Question 5

What is implementing?

Answer 5

Carrying out the care plan

Question 6

What is evaluating?

Answer 6

Measuring the extent to which patient achieved outcomes

Monitor the plan of care, if indicated

Question 7

What is an initial assessment?

Answer 7

Establish a complete database and provides reference base for problem identification, and future comparison

Done when new patient comes in and at shift change

Question 8

What is a problem focused assessment?

Answer 8

Ongoing process to determine the status of a specific problem identified in an earlier assessment

Short focused prioritized assessment

Question 9

What are emergency assessments

Answer 9

Occurs during physiological or psychological crisis to identify life-threatening problems and identify new or overlooked problems

Question 10

What are time lapsed assessments?

Answer 10

Occurs weeks to months after the initial assessment and compares current status to baseline to reassess health status

Question 11

Where do we get patient data?

Answer 11

From the patient

Caregiver

Medical record

Question 12

What are the two types of data?

Answer 12

Objective and subjective

Question 13

What is subjective data?

Answer 13

Information perceived by the affected person

Question 14

What is objective data?

Answer 14

Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them

Question 15

What type of data would you validate?

Answer 15

Any type of information that doesn’t make sense

SpO2 is 80% yet patient is breathing perfectly

Question 16

What is an appropriate nursing diagnosis

Answer 16

It should have 3 parts:

1) diagnosis/problem
2) related to (etiology/cause)
3) as evidenced by (which data supports the diagnosis?)

Question 17

What is an example of a nursing diagnosis

Answer 17

Patient has fluid volume deficit caused by nausea/vomiting/diarrhea as evidenced by 3 liquid stools in 24 hours, 250 ml of green emesis, dry mucous membranes

Question 18

What is a risk diagnosis?

Answer 18

There are no related factors (etiology factors) since we are identifying a vulnerability in a patient for a POTENTIAL problem.

The problem is not yet present

Question 19

What is an example for risk diagnosis

Answer 19

Risk for infection as evidenced by inadequate vaccination and immunosuppression

Question 20

What is the purpose of the planning step?

Answer 20

Design a plan of care with, and for the patient that results in prevention, reduction, or resolution of the health problem and attainment of the patient’s health expectations

Question 21

What is the method for the planning step?

Answer 21

Develop goals and outcomes, then design interventions to accomplish them

Question 22

What are some examples of setting priorities?

Answer 22

Which problems require my immediate attention or that of the team?

Which problems are my responsibility, and which should I refer to someone else?

Which problems are most important to the patient?

Question 23

What is the difference between goals and nursing interventions?

Answer 23

Goals: are what you want the patient to do or accomplish- not what you are going to do!

Interventions must relate to the goals you set, which must relate to the problems you diagnosed

Question 24

To be measurable, outcomes should have the following:

Answer 24

Subject- the patient or some part of the patient

Verb- the action the patient will perform

Conditions

Performance criteria- the expected patient behavior or other manifestation in observable, measurable terms

Target time- when the patient is expected to be able to achieve the outcome

Question 25

An example of a measurable outcome

Answer 25

During the next 24 hour period, the patients fluid intake will total at least 2000 ml

Question 26

Difference between direct interventions and indirect interventions

Answer 26

Direct: require patient contact

Indirect: actions taken away from the bedside but meant to support the patient goals like talking to a respiratory therapist

Question 27

What are the 3 main types of interventions?

Answer 27

Independent

Dependent

Collaborative

Question 28

What is independent intervention?

Answer 28

Nurse initiated interventions

No MD order required

Basic nursing care

Question 29

What are dependent interventions?

Answer 29

Physician initiated interventions

Requires MD orders

Question 30

What are collaborative interventions?

Answer 30

Coordination of multiple professionals

Question 31

What is a good way to approach the intervention step?

Answer 31

What are we going to:

Do, asses, teach, evaluate

Question 32

Why is the evaluation step a form of assessment?

Answer 32

Because you are assessing how well your patients have met their goals

If they aren’t meeting their goals, you are assessing why