Nurs 102: The Nursing Process

Front 1

What does 1st part, the assessing part of the nursing process, entail?

Back 1

Assessment includes: Data collection, organization, validation, interpretation, and documentation. Careful, it does not include analyzation, which is part of nurse diagnosing.

Front 2

What are the components of the diagnosing part of the nursing process?

Back 2

Diagnosing involves analyzing and synthesizing the collected data, identifying the health problems, risks and strengths, formulating diagnostic statements.

Front 3

What are the components of the Goal/Planning part of the nursing process?

Back 3

Prioritize the nursing diagnoses, formulate goals/desired outcomes, select nursing interventions, write nursing orders.

Front 4

What are the components of the Intervention/Implementation part of the nursing process?

Back 4

Reassess the client first, then decide if you'll need assistance, then implement interventions, supervise your delegated tasks, and then document what was done.

Front 5

What are the components of the Evaluation part of the nursing process?

Back 5

Collect data from the outcomes, compare original and new data with the outcomes, relate nursing actions to the client goals/outcomes, draw conclusions about the problem status, continue-modify-or terminate client's care plan.

Front 6

What sources can your data collection during assessment come from?

Back 6

Data collection from
Primary source- from the client by interview, health history, physical assessment
Secondary sources- family members, health care team members, medical chart

Front 7

Where does subjective and objective information come from?

Back 7

Subjective data are from the client’s feelings concerns generally obtained from the interview.
Objective data are what the nurse observes and obtains through physical assessment , lab and diagnostic tests

Front 8

Why is validation of data important and what kind of information validates subjective data?

Back 8

Validation helps to avoid omissions or incorrect inferences and objective information validates subjective information.

Front 9

What is an ACTUAL nursing diagnosis?

Back 9

A problem exists or is identified. Is composed of the diagnostic label, related factors and signs and symptoms.
Impaired Skin Integrity related to NPO status as evidenced by 3cm decubitus ulcer left heel.
It is a 3 part statement.

Front 10

What are the components of a RISK-FOR nursing diagnosis?

Back 10

This nursing diagnosis indicates that a problem does not exist, BUT RISK FACTORS are present.
The person is more vulnerable to develop the problem. More than another person. Start with “Risk for” or “High Risk for” depending upon vulnerability. Risk for Infection related to:
A break in skin integrity secondary to surgical incision, or Impaired healing
or NPO status.., It is a 2-part statement.

Front 11

What are 3 other types of Nursing Diagnoses besides Actual and Risk for. What are they?

Back 11

WELLNESS ndx: when a client wants a higher level of health like Potential for enhanced family process-do not use RELATED TO; also POSSIBLE ndx: describes a potential problem, but more data is needed like: Possible parental role conflict related to...(it is a 2-part statement),; fnally, COLLABORATIVE PROBLEMS ndx: identifies potential physiologic problems that could result and monitors client to detect changes, uses MD and nursing interventions to prevent, written like: Potential Complication: Asthma.

Front 12

What are some common errors found in nursing diagnoses?

Back 12

Writing a 2-part statement when it is an actual Nursing Diagnosis
Writing a 3-part statement when they type of diagnosis calls for a 2-part statement
Using the medical diagnosis in the diagnostic statement – in the “related to” section

Front 13

What are the similarities between a nursing goal/outcome?

Back 13

Goal= intent or end result. A broad statement which is client centered
Outcome= very specific. MUST have a time limit that is measureable and client centered
Similarities is that they are both client centered, but the goal is the broad statement with set intent. Oucome is more specific and it has a measurable objective with timeframe.

Front 14

What do each of the parts of client goal/outcomes, the verb, the modifier/condition, and the criterion mean?

Back 14

The verb is the word/action that the client will use to start achieving his goal. Examples: walk, measures, states, drinks... ; the modifier is how much, or the meaurable specific amount the client will do of each of the above verbs, walk 3 ft, measures 9cm., drinks 3 glasses.; the criterion is the time that the goal needs to be done by, whether for a STG or LTG. client will walk 3 ft BY END OF SHIFT.

Front 15

What is the key to the invervention part of the nursing process?

Back 15

ALWAYS START WITH reassessment! And remember that interventions use your critical thinking and creativity. What are all the ways that you can achieve a goal? Teaching, reporting, doing procedures, motivating,....Assessments, performing skills, planning for discharge
Establishment of priorities
Delegation to others, teaching,
Documentation
Following physician orders

Front 16

What are the Gordon's functional health problems?

Back 16

They are a framework for data collection that is based on 11 functional health patterns. This is how we can organize our data into clusters. You can check for ommisions and discrepencies.

Front 17

What are the common errors made in the planning part of the nursing process?

Back 17

Typical errors include:
Nurse centered
Unrealistic
Unmeasureable
No time frame

Front 18

How is evaluation done and what is important about the evaluation part of the nursing process?

Back 18

Evaluation includes the use of
Observation, Communication with client, and health care providers.
Goals are evaluated by: Standards of nursing care, Data collection, interventions, ongoing assessments, and Modifications of the plan of care.
Evaluation is an ongoing process...