Rusty's Nursing Process Lecture

Front 1

nursing used to be by the seat of the pants. each nurse doing their own thing. pre 1955 patient care was based on ...

Back 1

MD orders

Front 2

what person in 1955 coined the term nursing process?

Back 2

Lydia Hall

Front 3

1959-1063 a 3 step process was introduced. . who introduced the nursing process as a scientific model in 1966?

Back 3

Virginia Henderson

think Virginia Slims

Front 4

in 1967 a 4 step process was proposed. assessment, planning, intervention, and evaluation. what happened in 1973 by the ANA?

Back 4

published standards of clinical nursing practice

Front 5

1982 the nclex was revised. what happened?

Back 5

it included nursing process concepts

Front 6

in 1984, jacho required what?

Back 6

the use of the nursing process
jacho assess and evaluated hospitals on their quality of care, infection control, for certification for medicare payments.

Front 7

what is the purpose of the nursing process?

Back 7

id the health problem/care needs
establish patient goals
determine priorities
establish nursing interventions
evaluate effectiveness

Front 8

what is a process?

Back 8

a series of events
one event leads to another
all events work toward a goal achievement

Front 9

there are 5 steps in nursing process? assesssment, anaylsis, planning, impemenet, evaluation
how do you assess?

Back 9

physical assessment
health history
lab/diagnostic exams
team members
medical records
patient themselves
family too

Front 10

so the physical assessment part
what happens here?

Back 10

inspection
palpation
percussion
auscultation

Front 11

what happens with the health history part of the assesssment?

Back 11

establish a relationship
communication skills are needed
verbal and nonverbal

Front 12

the lab results help the physical assessment too. how?

Back 12

verify knowlege
it is objective information
suggest new findings

Front 13

what do we glean from the team members?

Back 13

new info
a new slant
this requires good com skills

Front 14

what can we pick up from the family?

Back 14

meds
mobility
reality info
its all subjective but critical info

Front 15

what can medical records tell us?

Back 15

past hospitalizations
past medical history

Front 16

how should we proceed in data collections?

Back 16

be descriptive
concise
complete
NO interpretive statements

Front 17

what are the types of data?

Back 17

subjective and objective data
sub = what the patient says
what pain feels like
Ex. patient says they are nausea
anything we cannot see is subjectve

Front 18

what is objective data?

Back 18

what you see
lab results are objective
concrete data, we can see it
smell

Front 19

there is the anaylsis of nursing diagnosis. This is the 2nd part after assessement. what is it?

Back 19

description of patient's actual/potential response to health problems.
It purpose it to:
analysis data, id problems, provide direction for the care plan

Front 20

there is an evolution to the diagnosis part of the nursing process. can you describe it?

Back 20

used to be only MD could diagnose.
conference in 1973 was held to classify nursing diagnosises. yea woopie!

Front 21

what is NANDA and so what?

Back 21

north american nursing diagnsos ass. formed in 1982. it listed acceptable nursing diagnosis,

Front 22

there is the medical diagnosis and there is the nursing diagnosis. YOU BETTER KNOW the difference. describe the MD diagnosis

Back 22

determined by MD
indicates a disease
diagnosis remains same until recovery
Ex. pneumonia, COPD, renal failure

Front 23

what is an example of the nursing diagnosis?

Back 23

well first of all its determined by a nurse and not a doctor.
the nursing diagnosis indicates a patient's response to treatment
Ex. risk of impaired skin integrity
Ex. knowledge deficit
Ex. self care deficit

Front 24

there is a 3 part format to nursing diagnosis:
diagnosis statement
related factors
what else?

Back 24

problem dia. statment
cause related factors
symptoms as manifested

Front 25

Then the 3rd part of the nursing process is planning. you establish priorities. how do you establish the planning priorities?

Back 25

rank diagnosis in order of important
maslov's hieracrhy
basic needs
when possible, involve patient

Front 26

planning has goals and outcomes right?
so what ?

Back 26

what = specific statement of patient behavior response.
why? provides direction of care
shows if interventions are effective
ishow we evaluate patients response to care
then we can go back to the goal and see if it has been achieved

Front 27

the goals of the planning should be:

Back 27

specific and measurable
have a time frame
are patient driven

Front 28

what about intervention of the nursing process? what is intervention?

Back 28

selected after goals are established
what are they? actions to accomplish the goals
are nurse driven
should indicate who, what , when, and how

Front 29

then the implementation of the nursing process, step 4.
what is this? the implementation?

Back 29

putting the plan into action!
you do this by delegation.
who, how to decide?
by their level of education and scope of the job/practice
expertise/competence

Front 30

so the internventions are continually reassess why?

Back 30

to re evlauate to make sure the interventions are approapriate b/c the patient's condition could of changed.

Front 31

the last step, step 5 is evaluation. did it work? what now?

Back 31

we use the nursing care plan here: