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84 Cards in this Set
- Front
- Back
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What is the primary purpose of the Nursing Process?
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To help nurses manage each patient's care scientifically, holistically and creatively.
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Additionally what is also a key component of the Nursing Process?
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critical thinking (when working with pt.)
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Steps of the Nursing Process is this remembered by this acronynm: ______ and list each
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A - assessment
D - diagnosis P - planning I - implementation E - evaluation |
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Describe the purpose of each of the five components of the Nursing Process:
Assessment |
A - performing a nursing assessment.
Implement by collecting health assessment data, lab data, subjective data about the client using physical assessment and interviewing techniques |
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Describe the purpose of each of the five components of the Nursing Process:
Diagnosis |
D - diagnosis - making nursing diagnosis by using client data and critical thinking skills to identify and validate the patient's strengths and weakness of actual or potential problems
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Describe the purpose of each of the five components of the Nursing Process:
Planning |
P - planning - formulating and writing outcome/goal statements & determining appropriate nursing interventions based on evidence (research)
Identifies the desired outcome and rules/out nursing interventions |
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Describe the purpose of each of the five components of the Nursing Process:
Implementation |
I - implementation- the nurse carries out the care plan and performing the interventions
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Describe the purpose of each of the five components of the Nursing Process:
Evaluation |
E - evaluation - the extent to which the patient achieved the outcome; making necessary revisions in care as needed.
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It was the _____ _______ _____ who legitimized the nursing process in 1973 given the following definition: "Nursing is the protection, promotion and optimization of health and abilities., prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response and advocacy in the care of individuals, families, communitites and populations." (Taylor, p. 209).
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American Nurses Association (ANA)
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A blend of what four major skills are needed to be mastered to perform successfully as a nurse?
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Cognitive
Technical Interpersonal Ethical/Legal skills |
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Define the four major types of skills of nursing:
Cognitive skills |
make sense of the situation and grasp what is necessary to achieve goals
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Define the four major types of skills of nursing:
Technical skills |
manipulate equipment skillfully to produce desired outcome
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Define the four major types of skills of nursing:
Interpersonal skills |
establish and maintain caring relationships that facilitate achievement of goals
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Define the four major types of skills of nursing:
Ethical/legal skills |
personal moral code and professional role responsibilities
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What is the goal of critical thinking?
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= clarity, precision, relevant, consistent, logical and fair-mindedness.
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What are the 6 steps towards developing a Method of Critical Thinking?
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1. Purpose of thinking
2. Adequacy of thinking 3. Potential problems 4. Helpful resources 5. Critique of judgement/decision 6. Focused critical thinking guides |
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6 Steps towards Method of Critical Thinking:
1. Purpose of thinking |
First, to identify the purpose or goal of your thinking and to direct all your thought towards that goal.
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6 Steps towards Method of Critical Thinking:
2. Adequacy of thinking |
Next, you will want to honestly evaluate or judge whether you have the knowledge needed to draw a sound conclusion.
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6 Steps towards Method of Critical Thinking:
3. Potential problems |
In order to do [adequacy of thinking] you must consider all the relevant details including what is at stake and how much time you have to make that decision, how much room for error is there?
Must learn to recognize faulty reasoning and do not let bias color their logic or allow emotion to determine the conclusion |
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6 Steps towards Method of Critical Thinking:
4. Helpful resources |
committed to life-long learning and know what resources needed to be tapped and when. (e.g. experienced colleagues, texts, journals, and institutional polices and professional writings)
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6 Steps towards Method of Critical Thinking:
5. Critique of judgement/decision |
A good critical thinker will identify alternative judgments and weigh the merits of each in order to reach a conclusion.
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List what are the characteristics of the nursing process?
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Systematic
Dynamic Interpersonal Outcome oriented Universally applicable |
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Characteristics of the nursing process:
Systematic |
means that it is a problem-solving approach that follows an ordered sequence of activities
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Characteristics of the nursing process:
Dynamic |
great interaction and overlapping among the five steps
it takes place within the relationship between the patient and the nurse and that the process flows throughout that relationship. |
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Characteristics of the nursing process:
Interpersonal |
human being (patient) is always at the heart of nursing process
The patient's perspective is of the utmost importance. |
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Characteristics of the nursing process:
Outcome oriented |
nurses and patients work together to identify outcomes.
Outcomes depend on the previous steps accuracy. |
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Characteristics of the nursing process:
Universally applicable |
a framework for all nursing activities
The NP is the framework for all nursing activity. One constant factor with nursing is flexibility, adaptability and change. |
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What are the benefits of the Nursing Process to:
Patients |
-Scientifically based, holistic individualized patient care
-Continuity of care -Clear, efficient, cost-effective plan of action |
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What is needed for the Nursing Process to benefit the nurse and patient?
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-Synergy is a dynamic process that happens in the relationship between the patient and the nurses
-It occurs when the patient's needs are perfectly matched by the nurses characteristics within the healthcare system. |
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What are the benefits of the Nursing Process to:
Nurses |
-Opportunity to work collaboratively with other healthcare workers
-Satisfaction of making a difference in lives of patients -Opportunity to grow professionally |
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What are "care plans"? (def.)
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a guide for clinical care
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What is the purpose for care plans?
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A major purpose of the nursing care plan is that it enhances communication between nurses on different shifts, which ultimately enhances coordination of services and sets a blueprint for evaluating care.
It allows for quick identification of diagnoses, expected outcomes, goals and interventions. As a nursing student you are expected to include evidence- based rationales in order to demonstrate understaning of the concepts. |
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A ______ care plan may include other info such as rationale for interventions or pathophysiology or etiologies to demonstrate understanding of concepts?
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student
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Steps of the Nursing Process:
Nurses and patients work together as partners to...(OR what are the aims of prof. nursing? (4) |
-Promote health
-Prevent disease/illness -Restore health -To facilitate coping with disability/altered functioning or death |
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ADPIE Step 1:
Assessment |
-Comprehensive assessment leads to an appropriate client outcome
= Collection of information about the client -Supports critical thinking -Beginning and ongoing during all phases of nursing process |
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T/F: A nursing assessment duplicate a medical assessment.
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False. Nursing assessment instead focuses on the patient's response to health problems.
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Nursing assessments on based on ________ _______.
Some examples include (3): |
conceptual models
-Gordon's functional health patterns -**Orem’s self-care model -Roy’s adaptation model |
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What is the purpose of Nursing Assessment?
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To establish a complete database concerning all aspects of the pt.'s health in order to est. priorities and to create a point of reference in which to develop a plan of care.
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What are the methods of collecting assessment data?
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-Interview
-Nursing health history -Physical examination -Diagnostic and laboratory results |
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T/F: Assessment is the working phase in which a nurse is to gather most of the detailed data. It is a time to ask personal questions if necessary-not during orientation.
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T:
Use critical thinking skills to modify questions as needed to get right data. – as a nurse you will need to practice your cultural competency at this time and the use of a translator may be required. |
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How is critical thinking applied to Nursing Assessment? Good questions to ask?
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By
Looking for normal and abnormal findings Validating the data with the client Good questions to ask: “This is what I have noticed.” “Does this describe how you feel?” “Tell me more.” “What can I do to help?” |
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What is "immediate reporting"? Examples on when to implement?
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Report and record information that requires immediate action during times such as examples:
-Sharp unrelenting pain -Vital signs greatly deviated from normal -a change in lvl of consciousness Good rule of thumb is: When in doubt, report! |
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How to provide and protect patient confidentiality?
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-Share only information that is of benefit to the nursing and medical team for planning care
-Keep notes safe -Do not leave at site of interview |
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What to do with Assessment info collected? Organize the information by:
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-Identify patterns
-List problems and group like problems together (ask: Which problems are the most clinically significant or urgent ones?) -Make initial inferences -Prioritize the problems -Document and report the information |
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ADPIE Step 2: Diagnosis
Three purposes to Nursing Dx. |
1. To identify how an individual, group or community responds to actual or potential health and life processes.
2. Identify factors that contribute to or cause health problems the other word for this is (etiology). 3. Identify resources or strengths the individual, group or community can draw on to prevent or resolve problems. |
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An easy way to refer to three -part Dx statement known as _____
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P(problem)
E(etiology) S(symptoms) |
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What does the "P" mean in Dx statement? Explain
Problem E S |
P (problem) - The nursing Dx label: a concise term or phrase that represents a pattern of related cues. The nursing Dx is taken from the official NANDA-I list.
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What does the "E" mean in Dx statement? Explain
P Etiology S |
E (etiology) - "Related to" (r/t) phrase or etiology: related cause or contributor to the problem
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What does the "S" mean in Dx statement?
P E Symptoms |
S (symptoms) - Defining characteristics phrase: symptoms that the nurse identified in the assessment
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Compare and contrast btwn.
Medical Dx vs. Nursing Dx. |
Medical diagnosis - focuses on disease
Nursing diagnoses - focuses on the unhealthy responses to health and illness. (i.e. MI (myocardial infarction) is a medical diagnosis whereas fever, altered tissue perfusion, altered health maintenance, knowledge deficit, pain are all likely nursing diagnosis for someone who has just had a recent MI.) It is the identification of the client’s needs leads to the formulation of a diagnosis that sets nursing apart from the practice of medicine. |
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Nursing Dx process involves
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-Analysis and interpretation of data
-Identification of client (self-care agent’s) needs and health problems -Orem style: see module Unit II (Evaluation of BCF, Evaluation of SCR (self-care requisites), Evaluation of Power components) |
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The types of problems should focus on relating to nursing diagnosis and management of health problems include:
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-Monitoring for changes in health status
-promotion and safety and prevention of harm -identifying learning needs -promoting comfort health, a sense of well-being -managing pain. -Also, recognizing barriers to a healthy lifestyle and the determining of human responses to health problems or life challenges are part of diagnosis. |
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How to prioritize nursing diagnoses?
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High (safety, tissue oxygenation, comfort/pain)
Intermediate (non-life threatening) Low (long term health care needs) ORDER OF PRIORITES CHANGES AS CONDITION CHANGES Periodically re-evaluate rankings in order to stay on top of a patient’s changing condition or readjusting outcomes in order to better meet the patient’s needs. |
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Actual, Risk, Wellness (Health Promotion), Possible and Syndrome are all known as what?
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5 different kinds of nursing Dx labels
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Actual (Nursing Dx)
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a judgment on clients response to a health problem that is present (e.g. Imbalanced Nutrition: more than body requirements...r/t...)
The actual nursing Dx is supported by defining characteristics & related factors (NANDA-I, 2009). |
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Risk (Nursing Dx)
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The client/family/community is vulnerable to developing the human response to a health condition/life process; based on most likely to develop
(e.g. Risk for imbalanced nutrition: more than body requirements:...) |
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Wellness (or Health Promotion Nursing Dx
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"A clinical judgment of a person's, family's, or community's motivation & desire to increase well-being & actualize human health potential as expressed by a readiness to enhance specific health behaviors such as nutrition and exercise" (NANDA-I, 2009).
(e.g. Effective Breastfeeding r/t ....). |
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Possible (Nursing Dx)
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A health problem is unclear and causative factor is unknown
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Syndrome (Nursing Dx)
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A group of s/s that usually occur together. Have both defining characteristics & related factors
(e.g. Post-Trauma syndrome r/t physical abuse aeb alienation, anger, anxiety, and depression) |
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What are the components of a nursing Dx process?
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-Diagnostic label
-Related factors—etiology -Definition (NANDA will describe use) -Risk factors (if not actual problem) -Support of the statement (as manifested by) |
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List steps of the PES formula to write nursing Dx 2 or 3-part statement.
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-State type of problem & diagnostic label (e.g. use NANDA-I)
-State related etiology or factors (R/T ) -State supporting data (as manifested by) |
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When documenting the selected Nursing Diagnosis on Nursing Plan of Care what questions should a nurse ask first?
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-Is my database sufficient, accurate and supported by scientific nursing knowledge and clinical expertise?
-Are the subjective and objective data congruent with the health problem defined? |
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ADPIE Steps: Planning
How to Write Measurable Outcomes |
Step 1. Assessment
2. Analyze assessment information. Formulate nursing diagnosis 3. Planning phase - Write measurable outcomes based on nursing diagnosis identified in the assessment |
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What is a "patient outcome"?
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an expected conclusion to a patient health problem
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When selecting/planning for patient outcomes make sure that:
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-Client-centered goals are selected (Orem: selecting goals for the self-care &/or dependent care agents to achieve)
-Expected outcomes are established -Nursing Interventions are selected (Orem: Devise nursing systems for interventions) |
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What does "NOC" mean?
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Nursing Outcomes Classification
= the standardized classification that describes outcomes for the specific Nursing Dx. to help provide the best goals for the client's condition--choose the one that fits your client's condition |
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How to select the appropriate outcome(s)? Questions to ask...
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-Use NOC (nursing outcomes classification)
OR -Write outcome statement Q to ask: Which problems can you address and which ones need to be delegated out? Which problems aren’t covered by protocols but must be addressed to ensure a safe hospital stay and timely discharge? |
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What is the purpose of NOC?
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It was developed to create a standardized language to describe patient outcomes that are responsive to nursing interventions in order to create a comprehensive approach to care planning.
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Measurable
Time frame Client-centered Attainable Realistic |
Criteria for writing nursing outcomes for client
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-What will the client change?
-How will you know? -What information will be needed to demonstrate the change? -What statement will the client make that demonstrates change? are all questions that apply ____ ____ when ______ ______ |
critical thinking, writing outcomes
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Planning:
Three categories of interventions are... |
-Nurse initiated
-Physician initiated -Collaborative –includes other team members |
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List step process for writing nursing outcomes
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Assessment
Formulate nursing diagnosis Planning --Write measurable, realistic, attainable client-focused outcomes with a time frame based on the nursing diagnosis identified in the assessment --Involve the client |
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Steps to complete the nursing process include:
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-Proceed to the next part of the planning phase
-Selecting appropriate interventions -Document all information on the nursing plan of care |
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To choose interventions consider the following:
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Etiological factors in Nursing Diagnosis
Defined E.O. Research/Evidence Based Practice Feasibility Acceptability Capability |
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What helps to inform nurses in selecting nursing interventions? (model)
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Orem's theory of self-care deficit
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What is the purpose of Interventions?
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actions performed by the nurse to: Monitor health status; Reduce risk; Resolve, prevent or manage a problem; Facilitate independence or assist with activities of daily living with the goal to promote optimal sense of physical, psychological and spiritual well-being (Alfaro-LeFevre, 2006, p. 170)
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Interventions may be either...
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Direct (Examples-give meds, start IV)
Indirect (Examples-maintain pt.safety,document in chart) |
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What is the "NIC"?
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Nursing Intervention Classification System (NIC) = the first validated list of nursing interventions applicable in all settings and greatly facilitates the work of identifying appropriate interventions
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What are the characteristics of NIC? (6)
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1. Appropriate in the terms of the Nursing Diagnosis
2. Consistent with EBR 3. Culturally sensitive and compatible with pt’s values and beliefs 4. Valued by the nurse and the patient 5. Compatible with other planned therapies 6. Must include rationales for assignments |
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What is the difference between nursing-initiated interventions and physician-initiated interventions?
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nursing-initiated = based on nurse’s judgment within scope of practice
-Determining and providing educational needs -Counseling ways to meet ADLs physician-init. = Standing Orders and Protocols Nurses are legally responsible for clarifying all orders that they carry out and must question the appropriateness of physician interventions . |
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Five classic elements of Evaluation
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-Identifying evaluative criteria and standards
-Collecting data -Interpreting and summarizing findings -Documenting judgment -Terminating, continuing, or modifying the plan |
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Two components of Evaluation are:
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-Examine situation or condition (after intervention)
-Judge whether change has occurred |
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When is the nursing process/care complete?
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Nursing care is not complete if the desired patient goals are not achieved.
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Nursing interventions must include the following
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Date
Verb: Action to be performed Subject : Who Descriptive phrase: How, when, where, how often, how much or how long |
