Nursing Process

Question 1

Wheel of the nursing process and their relationship to each other.

Answer 1

Theory, Experience, Research, Helping Process, Resource Utilization, Critical Thinking, Standards.

…………
…………

Question 2

Nursing Process is:
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Answer 2

• Systematic
• Rational
• Method of Planning
• Individualized Nursing Care

Question 3

DOH - 5 Steps

Answer 3

1. Assessment - Collection and interpretation of Clinical Information/Data.
2. Nursing Diagnosis - Actual vs Potential
3. Planning - T.R.A.M.P. - Set mutually defined, achievable measurable goal(s).
4. Implementation - Ongoing assessment, based on PHC principles, and Implement planned activities.
5. Evaluation

Question 4

Nursing Diagnosis: 
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Problem (Actual or Potential)
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4 Types of Statements:
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Answer 4

Clinical Judgment about individual, family or community responses to actual and potential health problems or life processes that is within the domain of nursing (NANDA 2007).

Actual: you take the actual problem that you see, link it to (ralated to) the contributing factors, and then link it to (Manifested by) Signs and Symptoms.
E.g. Impaired mobility —– r/t surgical pain —– m/b reluctance to get out of bed, moaning.

Potential: take a situation and predict a potential risk.
E.g. At risk for impaired mobility —- r/t pain from surgical incision.

1)
2)
3)
4)

Question 5

Medical Diagnosis:

Answer 5

“A medical diagnosis is the identification of disease condition on the basis of a specific evaluation of physical symptoms, the clients medical history, and the results of diagnostic tests and procedures.” (P&P, rev 4th ed., p.167)

Question 6

Goals: 
Guidelines + T.R.A.M.P.
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Answer 6

• Pt. focus (the pt. will…)
• Base goal on nursing
• Measurable/Observable descriptions/commentaries
• Time frame for goal achievement

Time Frame
Realistic
Achievable
Measurable
Patient Centered