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Nursing process

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systematic method of giving humanistic care that focuses on achieving outcomes in a cost effective manner

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What are the FIVE steps of the nursing process?

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Assessment Diagnosis Planning Implementation Evaluation

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Why do we use the nursing process for care planning?

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Requirement set forth by national practice standards (ANA, TJC) Basis for NCLEX exams Based on principles and rules that promote critical thinking in nursing

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What step in the nursing process is described by the following characteristics: First step in determining health status Gather information Gather all the "puzzle pieces" to put together a clear picture of health status Entire plan is based on data collected Data needs to be complete and accurate, make sense of patterns

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Assessment

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What are the five activities needed to perform a systematic assessment?

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Collect data Verify data Organize data Identify Patterns Report & Record data

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Initial assessment

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done shortly after arrival/admission

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Focused assessment

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focus on the complaint or specific problem that the patient expresses to you

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Emergency assessment

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focusing on the crisis at hand , identify the emergency problem and get that taken care of!

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Time lapse assessment

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done to compare a patients current status to base line data obtained earlier (what you found when you did vitals compared to what chart says)

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Comprehensive data begins __________ you see the patient (Nurse report from ER, Chart reviews)

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BEFORE

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What is important data to note about your patient during the nursing process?

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Name, age, gender, admitting diagnosis Medical/surgical history, chronic illnesses Advanced Directives Laboratory Data/Diagnostic tests Medications Allergies Support Services Psychosocial/Cultural Assessment Emotional state Comprehensive Physical Assessment

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What are things the nurse should note when doing a comprehensive physical assessment?

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Vital signs Height & weight Review of systems (neurological/mental status, musculoskeletal, cardiovascular, respiratory, GI, GU, skin and wounds. Standardized risk assessments: Pressure ulcers, falls, DVT

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Cluster data from patient into groups according to a nursing or medical model (_________ Basic Human Needs Model)

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Maslow's

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Cluster patient information by _________ or need deficit

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body system

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Clustering data helps maintain a nursing focus, allows __________ to be recognized

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patterns

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When diagnosing a patient the nurse will do an...

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Assessment, then Critical analysis of data collected and then create a Diagnosis or Problem Identification

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Novice nurse is ___________ for recognizing health problems, anticipating complications, initiating actions to ensure appropriate and timely treatment.

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responsible

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Nursing diagnosis provide a ____________ for selection of nursing interventions so that goals and outcomes can be achieved

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basis

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NANDA list of acceptable diagnoses, updated every ___________ years.

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2

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Diagnostic reasoning requires ______________, ___________, and _______________.

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knowledge, skill, and experience

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What are the fundamental principles of diagnostic reasoning?

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Recognize diagnoses Keep an open mind Back up diagnosis with evidence Intuition is a valuable tool for problem identification Independent thinker Know your qualifications ; limitations

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Actual Nursing Diagnosis

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actual evidence of signs/symptoms of diagnosis exist. (Fluid Volume Deficit)

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Potential/Risk for Nursing Diagnosis

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client's data base contains risk factors of diagnosis, but no true evidence (Risk for altered skin integrity)

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Writing an actual nursing diagnosis

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Actual Problems: Problem (NANDA label) & Etiology & Supporting Signs and Symptoms

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Impaired Communication related to language barrier as evidenced by inability to speak English

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nursing diagnosis with problem, etiology and supporting signs and symptoms

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Writing a potential for nursing diagnosis

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Potential or Risk Problems: Problem (NANDA label) & etiology or problem & risk factors with related to statement linking problem to risk factors.

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Risk for Impaired skin integrity related to obesity, excessive diaphoresis, and immobility.

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potential risk for nursing diagnosis

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When writing a nursing diagnosis one should follow these guidelines

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Use accepted qualifying terms (Altered, Decreased, Increased, Impaired) Don't use Medical Diagnosis (Altered Nutritional Status related to Cancer) Don't state 2 separate problems in one diagnosis Refer to NANDA list in a nursing text books

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What are the steps of the planning process for a nursing diagnosis?

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Set your priorities of care, what needs to be done first, what can wait. Apply Nursing Standards, Nurse Practice Act, National practice guidelines, hospital policy and procedure manuals. Identify your goals & outcomes, derive them from nursing diagnosis/problem. Determine interventions, based on goals. Record the plan (care plan/concept map)

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Short term goal

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Short term goal can be achieved in a reasonable amount of time ( few hours to few days) EX: Client will ambulate down the hall within 2 days.

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Long term goal

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Long term goals may take weeks/months to be achieved EX: Client will walk the length of the hallway independently by the end of 2 weeks

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When setting goals to achieve and monitoring the outcomes the nurse should remember?

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Be realistic in setting goals. (look at overall health state, growth & development level, prognosis) Set goals mutually with client Goals should be measurable, use measurable, observable verbs Identify one behavior per outcome When indicated use short-term vs. long tern goals

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Nursing interventions are actions performed by __________ to reach goal or outcome

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nurse

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Direct care intervention

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Direct action performed to client (inserting foley catheter)

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Indirect care intervention

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actions performed away from client ( looking at lab results)

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Independent nursing intervention has to be done following a physicians order, True or False?

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False

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Physician _____________ nursing order, can only be done following the physicians order

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dependent

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Collaborative nursing intervention

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interdependent nursing care performed by the nurse and other team members together

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Implementation consists of? *look over page 286 in Fundamentals book

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Putting your plan into action Set priorities after report Assess and reassess Perform interventions Chart client responses Give report to next shift

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Implementation of nursing interventions

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Describes a category of nursing behaviors in which the actions necessary for achieving the goals and outcomes are initiated and completed Action taken by nurse

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Protocols

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Written plan specifying the procedures to be followed during care of a client with a select clinical condition or situation

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Standing orders

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Document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedure for specific condition

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Implementation process involves

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Reassessing the client Reviewing and revising the existing care plan Organizing resources and care delivery (equipment, personnel, environment)

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Evaluation of individual plan of care includes

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Determining outcome achievement Identify variables/factors affecting outcome achievement Decide where to continue/modify/terminate plan Continue/modify/terminate plan based on whether outcome has been met (partially or completely) Ongoing assessment of QI

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Evaluation

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Step of the nursing process that measures the client's response to nursing actions and the client's progress toward achieving goals Data collected on an on-going basis Supports the basis of the usefulness and effectiveness of nursing practice Involves measurement of Quality of Care

Nursing Process Care Planning Ackley and Ladwig (115 exam 4) – Flashcards

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