Nursing Process

Front 1

What is the nursing process?
-A Delicious PIE

Back 1

Assess - Evaluate patient's condition
Diagnose - Identify patient's problems
Plan - Set goalds of care and desired outcomes
Implement - Perform nursing actions
Evaluate - Determine if goal was met

Front 2

Who is the primary source?

Back 2

Patient

Front 3

What is the first thing you do with a patient?

Back 3

Assess

Front 4

The physical Exam includes what four techniques?
I Practice Patient Assessment
(IPPA)

Back 4

Inspection
Palpation
Percussion
Auscultation

Front 5

The nursing process is a _____________ approach

Back 5

systematic

Front 6

What three things are included in an assessment?

Back 6

Patient History
Physical Exam
Diagnostic studies

Front 7

What are examples of subjective data?

Back 7

"I feel short of breath"
Only patient can provide this

Front 8

What are examples of objective data?

Back 8

Signs you can see, feel, hear, or smell.
Palpate a bilateral rhonchi

Front 9

Includes information about a patient's physical and developmental status, emotional health, social practices and resources, goals, values, lifestyle, and epectations about the health care system.

Back 9

Health History

Front 10

What nursing process is this?
A clinical judgement about an individuals response to actual and potential ealth problems or life processes.
-Patien's response to a health problem that the nurse is licensed to treat.

Back 10

Nursing Diagnosis

Front 11

What to do in a Diagnosis?

Back 11

Interpret data
compare it with definign characteristics
Identify related factors
find the problem, etiology, signs/symptoms

Front 12

What nursing process is this?
Ineffective airway clearance related to (R/T) excessive secretions as manifested by (AMB) weak cough, bilateral rhonchi

Back 12

Diagnosis example

Front 13

Physiological complication that nurses monitor to detect the onset of changes in a patient's status.

Back 13

Collaborative Problem

Front 14

Assessment questions when asking how patient performs routine tasks.

Back 14

How does your feeling tired affect the way you are able to do household chores?
"What did you do in a typical day before you got cancer?"

Front 15

Assessment questions to ask about lack of energy affecting patient physically.

Back 15

Do you have more energy after you sleep or rest?
How does feeling tired affect your interest in sexual activity.

Front 16

When Planning what do you do?

Back 16

Set goals and develop plan of action
Stablish priorities
Outcomes with time frames
Interventions
Document plan of care

Front 17

Planning must be ____ centered and ______

Back 17

Client; realistic

Front 18

Client will cough and expectorate sputum by 1600

Back 18

Example of planning

Front 19

Three types of planning interventions

Back 19

Independed
Dependent
interdependent (Collaborative)

Front 20

Things the nurse can order or do without a physician
-Turn, cough, and deep breath every 2 hours

Back 20

Independent

Front 21

Must be ordered by a physician
-Incentive spirometer every 2 hours

Back 21

Dependent

Front 22

Requires knowledge, skill, or expertise of other health care professions
-Breathing treatments every 4 hours and prn

Back 22

Interdependent (Collaborative)

Front 23

"Tell me the reason you came here"
-"Tell me about the problems you are having."
--Prompts to describe situation in more than 1 or 2 words

Back 23

Open ended question

Front 24

Positive comments such as "all right," "go on," or "uh-huh"

Back 24

Back-Channeling

Front 25

"How often do you feel really tired or fatigued."
-"After taking a nap do you feel more rested."
Yes or no answers or 1/2 word answers

Back 25

Closed-ended questions

Front 26

comparison of assessment data with another source to confirm accuracy.

Back 26

Validation

Front 27

Examples of Diagnostic Labels

Back 27

Compromised, decreased, delayed, walking, violence, urinary, trauma, tissue, pain, fatigue

Front 28

Shows type of pattern relationship with the diagnosis.
"The disease process of cancer" is making Mrs. mcphail fatigued."

Back 28

Related factor - Etiologies

Front 29

When do you consult?

Back 29

When you cannot solve a problem using personal knowledge, skills, and resources.

Front 30

What nursing process is this?
Performance of nursing interventions necessary for achieving goals and expected outcomes of nursing care.

Back 30

Implementation

Front 31

Treatments performed through interactions with patients
- IV catheter, counseling during time of grief

Back 31

Direct care interventions

Front 32

Treatments performed away from patient but on behalf of patient or group of patients
-safety, infection control, documentation

Back 32

Indirect care interventions

Front 33

What are the three implementation skills?

Back 33

Cognitive, Interpersonal, and Psychomotor

Front 34

Application of critical thinking skills
- therapuetic interventions, normal/abnormal responses

Back 34

Cognitive skills

Front 35

Trusting relationship between patient skills
-caring, communicate clearly, supporting

Back 35

Interpersonal Skills

Front 36

Skills that require cognitive and motor activities
-Wen taking a pulse you need to understand A&P (Cognitive) and assume proper positioning and use of touch to detect pulse correctly (Motor)

Back 36

Psychomotor Skills

Front 37

During Implementation, make sure you _____ the patient; is there a change in patient's status?

Back 37

Reassess

Front 38

__________ and ___________ the care plan - are the interventions still appropriate?
(Hint R&R)

Back 38

Review and Revise

Front 39

What Nursing Process is this?
Was the goal met?
Were changes needed?
ex- Goal met - expectorating white sputum
Goal not met - Continues weak cough and no expectoration

Back 39

Evaluation

Front 40

Mr. Harvey goes weekly to the outpatient clinic to have his blood pressure checked. He smokes one pack of cigarettes per day. His BP is 146/88. His father died from heart disease at age 49 and his brother is recovering from a heart attack.

Assessment Data:
A. The patient will quit smoking by the end of the day today.
B. Teach the patient the risk factors of coronary artery disease
C. request an order from the physician for a nicotine patch.
D. BP is 146/88

Back 40

D. BP is 146/88

Front 41

What is the goal to question #40
A. The patient will quit smoking by the end of the day today.
B. Teach the patient the risk factors of coronary artery disease
C. request an order from the physician for a nicotine patch.
D. BP is 146/88

Back 41

B. Teach the patient the risk factors of coronary artery disease

Front 42

What is the intervention to question #40?
A. The patient will quit smoking by the end of the day today.
B. Teach the patient the risk factors of coronary artery disease
C. request an order from the physician for a nicotine patch.
D. BP is 146/88

Back 42

C. The physician will order a nicotine patch.

Front 43

Who introduced the idea of systematic method of assessment/ individualized care?

Back 43

Florence Nightingale

Front 44

The Purpose of nursing diagnosis focuses on a ____ than the actual problem

Back 44

response

Front 45

What are the components of a nursing Diagnosis?

Back 45

2 part statement
etiology

Front 46

Cause of problem
-"related to" or "due to"

Back 46

etiology

Front 47

Four nursing Diagnosis categories:

Back 47

Actual
Wellness
Possible
Risk or potential

Front 48

Nursing Diagnosis that displays specific signs/symptoms that relate to patient's problem and exist here and now?
- alteration in comfort, ineffective breathing pattern, impaired skin integrity

Back 48

Actual

Front 49

Nursing diagnosis that has no chief complaints or is just requesting info on improving health

Back 49

Wellness

Front 50

Nursing diagnosis that has evidence for a problem that didn't exist prior to receiving care, but bc of medical diagnosis there could be a possibility.
-possible imbalance nutrition, insufficient oral intake

Back 50

Possible

Front 51

Nursing Diagnosis situation that may cause difficulty in future:
- high risk for injury or high risk for sleep pattern disturbance

Back 51

Risk or Potential

Front 52

Classification system that assists with organizing patterns of human response to develop an appropriate nursing diagnosis

Back 52

Taxonomy

Front 53

What are the four steps of planning?

Back 53

Set priorities
Write goals
Develop expected outcomes
Planning nursing actions

Front 54

what step of planning determines the problem that poses the greatest threat to the patient?

Back 54

Setting Priorities

Front 55

What example of planning is this?
Patient will be free of infection throughout hospitalization
Lungs will remain clear postoperatively
pt's skin will be healed by 12/07

Back 55

Writing Goals

Front 56

What example of planning is this?
-sputum will remain white
pt. will remain afebrile
lungs clear to auscultation

Back 56

Expected Outcomes

Front 57

Part of planning in which nurse assists pt. to achieve goal?

Back 57

Nursing Actions

Front 58

What is the fourth step of the nursing process?

Back 58

Implementation

Front 59

What is the 5th and final step of the nursing process?

Back 59

Evaluation

Front 60

"Pt will walk unassisted lenght of hall 3 times by 9/19 (2 days) example of?

Back 60

Outcome Statement

Front 61

Pt walked lenght of hall 2 times on 9/19 is an example of?

Back 61

Evaluation

Front 62

What do we ask at the end of evaluation process?
Do we ____, _____, or _____ the plan?

Back 62

Continue, modify, terminate

Front 63

Is administering O2 an Independent, Dependent, or Interdependent Intervention?

Back 63

Dependent, bc O2 is a drug.

Front 64

What is the foundation for clinical decision making?

Back 64

The Nursing Process

Front 65

"A patient tells the nurse, "I have had this dull ache in my side now for 4 days; it really hurts when I bend over." the nurse responds, "uh huh -- go on." The nurse's response if an example of:
1. Inference
2. Cue
3. Back-Channeling
4. Open -ended question

Back 65

Back Channeling

Front 66

A patient has a pressure ulcer resulting from urine incontinence and sustained pressure over her coccyx. The nursing plan of care includes a goal of "Pressure ulcer will heal in 3 weeks." Which of following is evaluative measure for goal?:
1. Turn patient every 90 minutes
2. Measure diameter of ulcer
3. Measure color of patient's urine.
4. Determine patient's report of discomfort during turning.

Back 66

2. Measure diameter of the ulcer

Front 67

A nurse has been interviewing a newly assigned patient. The cues from the assessment suggest that the patient has had a problem with breathing. The nurse does not validate the finding by doing a physical examination. This is an example of what type of error?
1. Error in data clustering
2. Error in data collection
3. Error in diagnostic statement
4. Error in interpretation and analysis

Back 67

4. Error in interpretation and analysis

Front 68

Roberta is a nursing student reporting off at the end of her shift to John, an RN. Roberta tells John that her patient has a priority nursing diagnosis of pain. She tells John the last time the ordered analgesic was given was 2 hrs ago. The patient continues to report pain at a level of 4. Roberta also tried repositioning and distraction to reduce the patient's discomfort. Roberta has observed her patient grimace while turning. What expected outcome measure did Roberta report to John?
1. Administartion of the analgesic as ordered
2. The use of distraction as a pain-relief measure
3. The reported pain level of 4 on a scale of 0 to 10
4. Observation of the patient grimacing during turning

Back 68

3. The reported pain level of 4 on a scale of 0 to 10

Front 69

The nurse prepares to administer care to a patient by first positioning him more comfortably. She inspects his surgical wound and reinforces the dressing with exra tape. The nurse explains the procedure she will use for insertion of a urinary catheter. She prepares the patient and inserts the catheter. Which of the following steps was a dependent nursing intervention?
1. Insertion of the urinary catheter
2. Reinforcement of dressing with tape
3. Instruction about the procedure for insertion of the urinary catheter
4. Positioning the patient for comfort

Back 69

1. Insertion of the urinary catheter

Front 70

A nursing student completes an assessment of a patient who just returned from a diagnostic procedure. The patient's BP is 92/70 mm Hg, and the patient reports feeling dizzy. The student goes to the medical record to learn what the patient's blood pressure and symptoms were before the diagnostic test. The nursing student's review of the medical record for data is an example of:?
1. Validation
2. Data analysis
3. Consultation
4. Outcome measurement

Back 70

1. Validation

Front 71

Mrs. Weber is a 52-year old patient who is facing reconstructive breast surgery. She has not had surgery in the past and is asking questions of the nurses in the outpatient surgery center. Mrs. Weber tells the nurse she would like to know more about what to expect. The nurse identifies the nursing diagnosis of readiness for enhanced knowledge related to planned surgery. An example of a goal for this diagnosis would be:
1. Provide instruction on routine postoperative monitoring
2. Perform vital sign measurement every hour following surgery
3. Patient identifies reason for vital sign monitoring following surgery
4. By day of surgery, patient understand the routine monitoring protocol following surgery

Back 71

4. By day of surgery, patient understands the routine monitoring protocol following surgery

Front 72

Mr. B, a 47 year old male patient goes to the annual community health fair. During a routine blood pressure screening, it is determined that his BP is significantly above normally expected levels.
What additional assessment data should be obtained from the patient and family?

Back 72

Additional data about patient's medical history and current health status.

Front 73

Mr. B returns for a follow up visit at the medical center's adult health clinic. Mr.B is diagnosed with hypertension and an antihypertensive medication is prescribed, but he appears unsure about how and when he should take the prescription. He also identifies that his father died from a heart attackat 54 years old.
Identify the relevant assessment data for Mr. B.

Back 73

Hypertension
prescription of antihypertensive medication
insecurity about medication regimen
relating fathers death at age 54 from Heart Attack

Front 74

What are the three phases of the interview?

Back 74

Orientation phase, working phase, and termination phase.

Front 75

Based on following data cluseters, identify possible nursing diagnoses:
Abdominal pain, three loose liquid stools per day, hyperactive bowel sounds.

Back 75

Diarrhea

Front 76

Based on following data clusters, identify possible nursing diagnoses:
Fatigue, weakness, tachycardia upon activity, exertional dyspnea:

Back 76

Activity Intolerance

Front 77

A new graduate is preparing to work with patients on a medical unit. The nursing process is applied as a :
1. Method for processing the care of many patietns
2. Tool for diagnosing and treating patient's health problems
3. Guideline for determining the nurse's accountability in patient care
4. Logical, problem-solving approach to providing patient care.

Back 77

4. Logical, problem solving approach to providing patient care.

Front 78

Upon admission, the nurse begins to assess the patient, The patient appears uncomfortable, stating that she has severe abdominal pain. The nurse should:
1. Inquire specifically about the discomfort
2. Let the patient rest, returning later to complete the assessment
3. Perform a complete physical examination immediately
4. Ask the family about the patient's health history

Back 78

1. Inquire specifically about the discomfort

Front 79

The following nursing diagnoses are proposed for patients on the medical unit. The diagnostic statement that contains all of the necessary components is:
1. Impaired gas exchange related to accummulation of lung secretions
2. Imbalanced nutrition related to chemotherapy treatment
3. Complicated grieving
4. Pain related to abdominal surgery

Back 79

1. Impaired gas exchange related to accummulation of lung secretions.

Front 80

A nurse is working with patients who go to the community center for health screenings and educational sessions. An example of a wellness nursing diagnosis label that is appropriate for this group is:
1. Risk for impaired skin integrity
2. Readiness for enhanced family coping
3. Altered parent-infant attachment
4. Fluid volume deficit

Back 80

2. Readiness for enhanced family coping

Front 81

In reviewing the nursing diagnoses written by a new staff memeber, a supervisor identifies which of the following as a correctly written nursing diagnosis?
1. Altered respiratory function related to abnormal blood gasses
2. Urinary infection related to long-term catheterization
3. Deficient knowledge related to need for cardiac monitoring
4. Pain related to severe arthritis in finger joints.

Back 81

3. Deficient knowledge related to need for cardiac monitoring.

Front 82

A nurse is working with a patient who has the following symptoms: dyspnea, ankle edema, weight gain, abdominal distention, hypertension. The nursing diagnosis that is most apropriate for these signs and symptoms is:
1. Ineffective tissue perfusion
2. Disturbed body image
3. Impaired gas exchange
4. Excess fluid volume

Back 82

4. Excess Fluid Volume

Front 83

There are a number of activities that are to be performed by a nurse during a clinical shift. In deciding to perform a nurse-initiated intervention, the nurse:
1. administers oral meds
2. orders lab tests
3 changes sterile dressing
4. Teaches newborn hygienic care

Back 83

4. Teaches newborn hygienic care