Nursing 1St Semester: Exam 1- Nursing Process

Front 1

What are the phases of the nursing process?

Back 1

Assessment
Diagnosis (Nursing Diagnosis)
Planning
Implementation
Evaluation

(AD PIE)

Front 2

What is involved with the assessment step of the nursing process?

Back 2

data collection (vital signs) weight etc.
MAR (medical record)
Physical Assessment
Interview
OTC meds- supplements, vitamins, recreational drugs etc.
Allergy assessment
Health history (surgeries, fractures)
Family history (genetic disease info)
Subjective and Objective Data
Environment- home/work life

Front 3

Subjective Data

Back 3

feelings, opinions, expressions (feedback from patient)

Front 4

Objective Data

Back 4

what we can see, touch, evaluate (measurable)

Front 5

What is involved with Nursing Diagnosis?

Back 5

General survey- 60 sec check(color, speech, mobility, LOC)
Data analysis
Clustering information Determine strengths, determine unmet needs
Nurses Diagnosis (NANDA nursing diagnosis)
Physical Exam (objective data) -
Types, techniques (palpation & osculation)
equipment

Diagnostic Statements
PES (S is first)

Front 6

What is involved with the Planning phase of the Nursing Process?

Back 6

Outcomes, Goals, Interventions
Priority setting- Patient’s greatest concern (safety need vs. physical need)
Measurable

Front 7

What is involved in the implementation phase of the Nursing Process?

Back 7

activation of the plan
Should be patient centered and individualized
Measurability- what specific outcomes do we expect?
Delegation

Front 8

Describe the evaluation phase of the Nursing Process

Back 8

It's Continuous
Was it realistic to the specific patent?
Was the outcome or goal met?

Front 9

Describe the components of the PES model in nursing diagnostic statements.

Back 9

"S"is first Signs & Symptoms (assessment, verbalization)
P-Problem
E- Etiology (manifestation source of problem)


Connect problem to etiology

Connect the etiology to the signs and symptoms

Front 10

Actual Nursing Diagnosis

Back 10

related to patient condition or disease process, identified through data collection, using PES
Ex- diabetic, low blood sugar levels

Front 11

Potential Nursing Diagnosis

Back 11

may occur based on patient condition, intervention, or disease process
Only identifies problem & etiology
Ex- risk of infection from a surgical procedure (etiology)

Front 12

Describe guidelines for writing an outcome statement

Back 12

Planning should be a collaborative effort between nurse and client (patient). The setting of more specific outcomes is necessary for systematic measurement of the patient’s progress. The nurse may write patient outcomes by describing/desired, realistic, measurable patient behaviors to be accomplished by a specific date
Ex- short term outcomes, the patient will maintain normal vital signs in response to activity in two days

Front 13

What to do if interventions have been effective

Back 13

What actually happened? Do we need to continue therapy? Is therapy ongoing?

If goal was met, what’s next? Revisit problem.

Front 14

What to do if interventions have been ineffective

Back 14

Revisit Problem, Go through Nursing Process with further research and detail