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15 Cards in this Set
- Front
- Back
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Nursing process |
A critical thinking process that consists of five steps to follow in a goal directed, systemic way to achieve optimal client outcomes!
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What are the five steps to the nursing process? |
– Assessment/data collection, analysis/data collection, planning, implementation, and evaluation. |
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Baseline data |
The information nurses collect during initial assessment. |
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Methods of data collection include: |
Observation, interviews with clients and families, medical history, physical exam, diagnostic and la reports, and collaboration. |
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When collecting data correctly RN's must... |
ask appropriate questions listen carefully have excellent head to toe examination skills Use clinical judgement and critical thinking. Also be aware of collecting data before interventions. |
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Subjective data |
(Symptoms) during a nursing history this data is collected. It includes the clients feelings, perceptions, and descriptions of health status. Clients are the only one who can describe and verify their own symptoms.
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Objective data
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(Signs) this data is observed and measured during a physical examination. It is what they see, feel, hear, and smell of the client.
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Secondary subjective data
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This is what others tell the nurse. For example, "Her should has been hurting all day"
Sources can be family, friends, caregivers, medical records. |
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Assessment/data collection requires the nurse to
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look at data and recognize patterns or trends, compare data with expected standards or reference ranges, arrive at conclusions to guide nursing care.
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Planning
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Nurses must establish priorities and optimal outcomes of care they can readily measure and evaluate. These priorities and outcomes of client care direct nurses in selecting interventions to promote, maintain and restore health.
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Interventions and types
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Help to achieve optimal outcomes.
Nurse initiated/independent interventions, provider initiated/dependent interventions, collaborative interventions. |
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Implementation
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Step of the nursing process that requires problem solving, clinical judgement, and critical thinking to select and implement appropriate therapeutic interventions using nursing knowledge, priorities of care, and planned goals or outcomes to promote, maintain and restore health.
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Evaluation
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This step of nursing process evaluates the clients response to interventions and form a clinical judgement about the extent to which the clients have met the goals and outcomes.
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By the second postoperative day, a client has not achieved satisfactory pain relief. Based on thisevaluation, what should the nurse do next according to the nursing process?
A. Reassess the client to determine the reasons for unsatisfactory pain relief. B. See whether the pain lessens during the next 24 hr. C. Change the plan to ensure that the client achieves adequate pain relief. D. Teach the client about the plan of care for managing his pain. |
A is CORRECT: The nurse should reassess the client to determine why he has not achieved satisfactorypain relief. Various factors may be influencing the lack of pain relief
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A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: “The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away.” The instructor should inform the student that she left out which of the following steps of the nursing process?
A. Assessment B. Planning C. Intervention D. Evaluation |
A. CORRECT: The nursing student should have used the assessment step of the nursing process byasking the client to evaluate the severity of his pain on a 0 to 10 scale. She also should have askedabout the characteristics of his pain and assessed for any changes that might have contributed toworsening of the pain
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