Nursing Process Test Questions – Flashcards
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a systematic problem solving approach toward providing individualized nursing care.
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Define the nursing process
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North American Nursing Diagnosis Association International
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What is NANDA-I
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1-framework for care to indiv, families, & communities 2-orderly & systematic 3-interdependent 4-provides specific care for the indiv, fam, & comm 5- client centered 6-appropriate for use throughout lifespan 7-used in ALL settings
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What are the characteristics of the nursing process?
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ADPIE A=assessment D=diagnosis P=planning I=implementation E=evaluation
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What are the steps of the nursing process?
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1- initial (or admission assessment) 2- focused assessment 3- emergency assesment
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How does the nurse obtain assessment info?
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past medical hx - family hx - reason for admission - current meds - previous hospitalizations & surgeries - psychosocial assessment - nutrition - complete physical assessment
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How does the nurse obtain assessment info?
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Collects data about a problem that has already been identified. This type of assessment determines whether the problem still exists, or any changes.
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focused assessment
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‐ What are your symptoms? ‐ When did they start? ‐ What activity were you doing ? ‐ What makes it better or worse? ‐ What are you doing to relieve the symptom?
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focused assessment questions
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Performed to identify a life‐threatening problem (choking, stab wound, heart attack).
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Emergency assessment
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Information verbalized or stated by the client.
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subjective data
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‐ Observable and measurable information. ‐ Remember to include your senses: smell, hearing, touch and sight.
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objective data
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An objective finding perceived by the examiner ex. (fever, rash, etc.)
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sign
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Subjective findings verbalized or stated by the client ex. ("I have a headache" " I feel sick in my stomach.")
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symptom
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objective
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signs are
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subjective
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symptoms are
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primary & 2ndary
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2 sources of data
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‐Information obtained from the patient (only)
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primary source of data
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‐ Family members ‐ Significant others ‐ Past & current health records, laboratory tests,diagnostic procedures, consultations from other healthcare professionals.
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secondary sources of data
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VALIDATE ‐Confirm and verify the information. ‐ Keep it free from errors, bias, or misinterpretation.
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collect the data then BLANK the data
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collected, validated, then clustered
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Data is 1,2,3
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defining characteristics which are specific assessment findings that support a nursing diagnosis.
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clustering of data often contains
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critical thinking is used to analyze and synthesize the information that is collected. The data is then put into specific clusters that describe a specific client problem.
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during the clustering of data what is used
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subjective & objective, primary & secondary, people, healthcare professionals, medical chart, test & lab results etc
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identify sources of data for obtaining information from the client
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As you cluster data, you begin to consider various diagnoses that may relate to the client. You must remember that if certain defining characteristics do not exist for a specific diagnosis, then you must not use the diagnosis.
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identify how you develop a nursing diagnosis
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1. Complete thorough assessment of the patient. 2.Highlight or underline relevant symptoms (defining characteristics). 3. Make a list of symptoms. 4. Cluster and interpret the symptoms. 5. Analyze and interpret the symptoms. 6. Select a nursing diagnosis based on the definition found in the nursing diagnosis manual by Doenges, Moorhouse and Murr. 7. Remember to prioritize the identified problems.
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identify how you develop a nursing diagnosis (what is first / next etc)
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A medical diagnosis describes a disease process. A nursing diagnosis describes an individual, family or group response to an actual or potential problem.
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what is the difference between a medical and nursing dx
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‐Identification of a disease condition based on specific findings such as diagnostic tests and procedures. ‐ Remains the same as long as the disease is present.
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medical dx
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‐ Clinical judgment in response to actual or potential health problems. ‐ Provides a basis for providing nursing care through various interventions to achieve outcomes. ‐ Changes possibly from day to day as the patient's response changes.
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nursing dx
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1. Actual diagnosis 2. Risk diagnosis 3. Health promotion diagnosis 4. Wellness diagnosis
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what are the 4 types of NANDA-I dx
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Represents a problem that has been validated by the presence of defining characteristics (signs and symptoms).
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actual dx
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Is defined by NANDA‐I , "describes human responses to health conditions/life processes that may develop in a vulnerable individual, family, or community. It is supported by risk factors that contribute to increased vulnerability" (NANDA, 2007). Ex. infection after surgery
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risk dx
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Clinical judgment of a person, family, or community desire to enhance their well being and readiness to implement health behaviors of a higher level. Ex. nutrition
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health promotion dx
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Describes the human responses to levels of wellness in an individual, family or community that have readiness to enhance well being. Ex.Coping, readiness of enhanced related to successful cancer treatment.
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wellness dx
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A nursing diagnosis consists of 3 parts or what is referred to PES format: P= Problem E =Etiology S =Signs and Symptoms
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how do you formulate an actual nursing dx; what does it consist of
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to identify the health status or problem of the individual using the approved NANDA - I list. Ex.Pain, acute
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what is the purpose of the problem
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the cause ; Identifies the physiologic, psychological, sociologic, spiritual, or environmental factors assumed to be the cause of the problem or a contributing factor.
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what is the etiology
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"related to" ; The etiology cannot be related to a medical diagnosis.
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the etiology is linked to the problem with the phrase
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Identified as subjective and/or objective data that supports the problem. ‐ Identified by the nurse from the clustering of significant data including assessment findings.
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signs & symptoms
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"as evidenced by"
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signs & symptoms are linked to the etiology by the phrase
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consist of a problem and the etiology only - there are NO signs & sypmtoms because it hasn't happened yet
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how do you formulate a risk dx? what does a risk dx consist of?
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develop a plan of care.This is accomplished by developing client centered goals and expected outcomes. - use critical thinking to develop nursing interventions to resolve the client's problem and achieve the goals.
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what does the planning phase of the nursing process consist of
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1-Maslow 2- Pt preference what does the pt think is important 3-Anticipation or future problems
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3 helpful guides in prioritizing needs
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Maslow's Hierarchy of Needs a. physiological needs b. safety needs c. love and belonging needs d. self‐esteem needs e. self‐actualization needs
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Maslow
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1 -airway 2- urinary 3- sexual 4- skin integrity
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prioritizing nursing dx ex 1
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1-gas exchange 2-hypothermia 3-knowledge defecit 4- infection
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prioritizing nursing dx ex 2
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1-pain 2-mobility 3- social isolation 4-self esteem
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prioritizing nursing dx ex 3
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" a broad statement that describes the desired change in a client's condition or behavior."
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define a goal
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include expected outcomes or measurable criteria to evaluate the achievement of the goal.
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components of a correctly written goal
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an objective behavior or response you expect the client to achieve in a short period of time usually less than one week.
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short term goal
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An objective behavior or response you expect the client to achieve in a longer period of time possibly over several days, weeks, or months.
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long term goal
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An outcome is a measurable change in the client's status that you expect to occur related to the implemented care.
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what is an expected outcome
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1-client centered 2-singular 3-observable 4-measurable 5-time limited 6-mutual 7-realistic
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guidelines to remember when writing goals
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Are actions or treatments based on knowledge or judgment that the nurse performs to meet the patient outcomes.
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what are nursing interventions
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1-independent ex. positioning 2-dependent ex. med admin 3-collaborative or interdependent ex. OT
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what are the 3 types of nursing interventions - provide examples
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1-Failure to be precise or fully indicate the nursing action. 2-Failure to indicate frequency 3-Failure to indicate quantity 4-Failure to indicate method
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what are frequent errors when writing nursing interventions
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is the reason for choosing the particular intervention based on supportive evidence from textbooks, journals, and/or online nursing references (so we know why we are doing the task we are doing)
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what is the purpose of scientific rationale for student nurses
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This step begins after the care plan has been developed by the nurse. This is the step of the nursing process where the nurse performs the interventions as a means of achieving the goals.
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what is the implementation phase of the nursing process
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direct (performed through interaction with the client) or indirect (without the client but on their behalf)
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interventions can be BLANK or BLANK
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1-reassessing 2-review/revise existing nursing dx & care plan 3-organizing resources & delivery of care 4-Anticipating/preventing any complications 5-Implementing interventions
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the implementation process takes into account 5 activities
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1-cognitive 2-personal 3-psychomotor
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Implementing Interventions: requires 3 skills
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critical thinking ; good decisions
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Implementing Interventions :cognitive skills
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communication ; therapeutic interactions
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Implementing Interventions: personal skills
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proper performance and knowledge of skills
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Implementing Interventions ; psychomotor skills
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Evaluation is the final stage of the nursing process. You as the nurse determine if the patient has achieved the expected outcomes not if the nursing interventions were completed.
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what is the evaluation phase of the nursing process
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1. Identifying criteria and standards. 2. Collecting data to determine if the criteria or standards are met. 3. Interpreting and summarizing findings. 4. Documenting findings and any clinical judgment. 5. Terminating, continuing or revising the care plan.
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the evaluation phase has 5 components
