Kozier Ch 11-14 Overeview Unit 3 The Nursing Process - Fundamentals Of Nursing + Nclex Review? (Elisa)

Front 1

What is the nursing process? (Define)

Back 1

-An orderly, systematic framework for nursing practice
-Central to all patient-centered care
-Foundation for nursing care plans
(slide 2)

Front 2

What are the five steps of the Nursing Process? (ADPIE)

Back 2

-Assessment
-Diagnosis
-Planning
-Implementation
-Evaluation
(slide 3)(fig 11-1 p.178)

Front 3

What are 6 Characteristics of the Nursing Process?

Back 3

-Dynamic and cyclic
-Client centered/Holistic
-Planned and Outcome Directed
-Evidence based
-Flexible and creative
-Proactive and Improvement-Oriented
(slide 5)

Front 4

What is Assessment?

Back 4

The act of collecting, validating, organizing and recording data
(slide 6)

Front 5

Is Both subjective and objective data included in Assessment?

Back 5

YES
(slide 6)

Front 6

Define Subjective and give example

Back 6

-symptoms; what the patient or family tells you
(pain, anxiety, weakness)
(slide 6)

Front 7

Define Objective & give example

Back 7

-signs; what you can observe and measure
(vital signs, lab results, physical condition)
(slide 6)

Front 8

Define (Nursing )Diagnosis

Back 8

Nursing conclusion about the needs/problems of the patient.
(slide 7)

Front 9

Is the same as medical diagnosis?

Back 9

No its Different
(slide 7)

Front 10

How is (Nursing )Diagnosis Reached?

Back 10

-through a reasoning process used to interpret the assessment data
-Can be actual, potential (risk for) or possible diagnosis
(slide 7)

Front 11

What guidelines do nurses follow when writing (Nursing )Diagnosis ?

Back 11

Written according to NANDA format
(slide 7)

Front 12

What is the Planning stage?

Back 12

-Planning Both outcomes/goals and interventions
-Need to prioritize and specify time frame
(slide 8)

Front 13

What is Outcomes/goals?

Back 13

-what you want to have happen (measurable)
(slide 8)

Front 14

What are Interventions?

Back 14

-what you will do to facilitate reaching the goal
(slide 8)

Front 15

What is Implementation?

Back 15

-Action oriented
-Do, Delegate, Document
(slide 9)

Front 16

Why is Implementation important?

Back 16

-Helps to assure continuity of care
-Relies on ability to recognize patient readiness for interventions and to communicate goals clearly
(slide 9)

Front 17

What is important to remember about the patient during Implementation to increase positive outcome?

Back 17

Nurses Should be culturally sensitive and involve family/support if possible
(slide 9)

Front 18

What is Evaluation?

Back 18

Ongoing process
-Review outcome achievement
-Review nursing plan effectiveness
-Monitor and record/report patient response to medications
-Revise care plan as needed
(slide 10)

Front 19

Should patient/family input be included in evaluation?

Back 19

YES
(slide 10)

Front 20

What is the next step after Evaluation?

Back 20

ADPIE
And The Cycle Continues….

Front 21

The nurse has just been assigned to the clinical care of a newly admitted patient. Which step of the nursing process will the nurse probably do first in determining the patient’s plan of care?

A. Assessment
B. Diagnosis
C. Plan outcomes
D. Plan interventions

Back 21

Answer: A
Rationale: Assessment is the first step of the nursing process. The nursing diagnosis is derived from the data gathered during assessment; outcomes from the diagnosis, and interventions from the outcomes. A newly admitted patient typically receives a comprehensive assessment, which serves as the basis for the plan of care.

Front 22

The nurse changes a wound dressing every 8 hours. This is an example of which aspect of patient care?

A. Assessment data
B. Nursing diagnosis
C. Patient outcome
D. Nursing intervention

Back 22

Answer: D
Rationale: Interventions are activities that will help the patient achieve a goal, such as changing
a dressing to prevent wound complications. An example of assessment data might be: “Dressing has 5 cm of serosanguineous drainage.” The nursing diagnosis would be “Impaired Skin Integrity” or perhaps “Risk for Infection.” The nurse might define the patient outcome in this scenario as, “Wound will remain free of infection.”

Front 23

Which statement about the nursing process is correct?

A. It was developed from the ANA Standards of Care.
B. It is a problem-solving method to guide nursing activities.
C. It is a linear process with separate, distinct steps.
D. It involves care that only the nurse will give.

Back 23

Answer: B
Rationale: The nursing process is a problem-solving process that guides nursing actions. The ANA organizes its Standards of Care around the nursing process, but the process was not developed from the standards. The nursing process is cyclical and involves care the nurses give or delegate to other members of the health care team.

Front 24

A nurse uses a sensitive, creative and empathetic approach to adapt care to meet each patient’s unique needs. This best describes:

A. Nursing theory
B. Nursing art
C. Nursing process
D. Nursing definition

Back 24

Answer: B
Rationale:
• Nursing art is not so much what you know or do, but more about your approach to what you do.
• Nursing theory offers a way of looking at the discipline in clear, explicit terms that can be communicated to others.
• A nursing definition is a comprehensive statement that describes the nature of nursing.
• Nursing process is a special way of thinking and acting, but it is more than just the nurse’s approach; it is a problem-solving process.

Front 25

What is the most important reason for using the nursing process? It can:

A. Help ensure quality care for clients.
B. Assure that clients’ problems are solved.
C. Provide a permanent record of care given to a client.
D. Create opportunities for professional growth.

Back 25

Answer: A - help ensure quality of care for clients
Rationale: There are many benefits, to both nurse and patient, of the nursing process. However, the primary goal of nursing – and therefore the most important reason to use nursing process – is good quality patient care.

Front 26

Arrange the steps of the nursing process in the order in which the typically occur.

A. Assessment
B. Planning outcomes and interventions
C. Evaluation
D. Diagnosis
E. Implementation

Back 26

Answer: A, D, B, E, C
Rationale: Step order of: Assessment, Diagnosis, Planning outcomes and interventions, Implementation, and Evaluation.

Front 27

Which statement best describes the nursing process? It is:

A. A systematic, problem-solving approach to patient care.
B. A way to find solutions for nearly all patient problems.
C. Useful primarily by nurses in the hospital setting.
D. Linear in nature, occurring in separate, sequential steps.

Back 27

Answer: A - A systematic, problem-solving approach to patient care.
Rationale: The nursing process is a systematic, problem-solving approach to patient care. A solution to all patient problems is not possible, even with flawless application of the nursing process. Nursing process is not limited to inpatient nursing, but is useful in a variety of settings and with a variety of patients. It is cyclic in nature. The steps are not always sequential, and they overlap in practice.

Front 28

What kind of skills is the nurse demonstrating when questioning the reasons for a nursing procedure?

A. Interpersonal skills
B. Adaptability
C. Honesty
D. Curiosity and creativity

Back 28

Answer: D – Curiosity and creativity are most clearly and directly demonstrated in the
example given.
Rationale: Interpersonal skills may be needed in order to successfully question the reasons for the procedure; however, the questioning would demonstrate curiosity, even if it were most unskillfully done. The answer is not adaptability because one could question the reasoning and still be unable to adapt to any changes. Honesty is not required in order to recognize the need to question an action.

Front 29

How does nursing process benefit the nursing profession? It helps to:

A. Meet patient needs
B. Define nursing for the public
C. Improve job satisfaction
D. Make staffing assignments more efficient

Back 29

Answer: B– Define nursing for the public
Rationale: Meeting patient needs is a benefit to the client, rather than the profession. Improving job satisfaction is a benefit to the individual nurse, and only indirectly benefits the profession.
Making staffing assignments more efficient benefits nurses. You could argue that anything that benefits the nurse at least indirectly benefits the profession. However, you can choose only one answer, and “define nursing for the public” is the most clear and direct benefit to the nursing profession. Therefore, it is the best answer.