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What is the nursing process?
The nursing process is an organizing framework incorporating scientific reasoning, problem solving, and critical thinking for professional nursing practice.
Historical development of the nursing process.
  • 1955: "nursing process" term used by hall
  • 1960's: specific steps delineated
  • 1967: yura and walsh published first comprehensive book on nursing process
  • 1973: ANA Congress for Nursing Practice developed standard of practice
  • 1982: state board examinations for professional nursing uses nursing process as organizing concept
What are the five steps of the nursing process?
  • Assesing: collecting, validating, and communication of pt data
  • Diagnosing: analyzing pt data to ID pt strengths and problems
  • Planning: specifying pt outcomes and related nursng interventions
  • Implementing: carrying out the plan of care
  • Evaluating: measuring extent to which pt achieved outcomes
What is evidence based nursing?
Evidence based nursing is nursing practice based on research or "evidence". It promotes quality pt care and enhances the nursing profession.
What are the benefits of the nursing process for the pt?
  • Scientifically based, holistic individualized pt care
  • continuity of care
  • clear, efficient, coset-effective plan of action
What are the benefits of the nursing process for nurse?
  • oppurtunity to work collaboratively with other healthcare workers
  • satisfaction of making a difference in lives of pts
  • Opportunity to grom professionally
What four blended skills are essential to the nursing process?
  • Cognitive skills: make sense of the situation and grasp what is necessary to achieve goals
  • Technical skills: manipulate equipment skillfully to produce desired outcome
  • Interpersonal skills: establish and maintain caring relationships that facilitate achievement of goals
  • Ethical/Legal skills: personal moral code and professional role responsibilities
What are the characteristics of interpersonal caring?
  • promotion of dignity and respect of pts
  • centrality of the caring relationship
  • mutual enrichment of both participants in the nurse-pt relationship
Developing Ethica/legal skills
  • reveloping accountability
  • reporting incompetent, unethical, or illegal practice
What are the characteristics of critical thinking and clinical reasoning.
  • They are purposeful, informed, outcome-focused thinking
  • Are driven by pt, family, and community needs
  • Are baed on principles of nursing process and scientific method
  • Uses both intuition and logic, based on knowledge, skills, and experience
  • Requires strategies that make the most of human potential
  • Are constantly reevaluating, self-correcting, and striving to improve.
What is assesment?
  • Assesment is the systematic and continuous collection, validation, and communication of pt data.
  • It is accomplished through holistic nursing assesment of the pt
What is the difference between medical and nursing assesments?
  • Medical assesments target data pointing to pathologic conditions
  • Nursing assesments focus on the pt's response to health problems
What are sources of pt data?
  • The pt
  • family and significant others
  • Pt record
  • other healthcare professionals
  • nursing and other healthcare literature
What are Gordon's functional health patterns?
Gordon's functional health patterns is a method devised by Marjory Gordon to be used by nurses in the nursing process to provide a more comprehensive nursing assesment of the patient.
What are some problems related to data collection?
  • Inappropriate organization of the database
  • Omission of pertinent data
  • Inclusion of irrelevant or duplicate data, erroneous or misinterpreted data
  • failure to establish raport and partnership
  • recording an interpretation of data rather than observed behavior
  • failure to update the database
What are characteristics of good data?
  • It is complete
  • It is factual and accurate
  • It is relevant
When should you verify data?
  • when there is a discrepancy between what the person is saying and what the nurse is observing
  • when the data lack objectivity
  • when there is a discrepancy between what is in the record and what the nurse is observing
How should a nurse go about validating inferences?
  • perform a physical exam using proper equipment and procedure
  • use clarifying statements
  • share inferences with other team members
  • checking findings with research reports
What is the difference between objective and subjective data?
  • Objective data is observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them (eg. telp, skin moisture, vomiting)
  • subjective data is information perceived only by the affected person (eg. pain, dizziness, anxiety, nausea)
What is a key part of formulating a nursing diagnosis?
Data collection
What is the purpose of the diagnosing step?
  • ID the pt response to actual or potential health problems
  • ID factors that contribute to or cause health problems (etiologies)
  • ID resources or strengths the pt can draw on to prevent or resolve problems
What are the nursing concerns and responibilities?
  • Monitoring for changes in health status
  • promoting safety and preventing harm
  • Identifying and meeting learning needs
  • Promoting confort and managing pain
  • promoting health and well-being
  • addressing prblems that limit independence
  • determing human responses
What is the difference between a nursing and medical diagnosis?
  • A nursing diagnosis describes pt problems that nurses can treat independently
  • A medical diagnosis describes problems for which the physician directs the primary treatment
What are collaborative problems?
They are problems that are managed by using physician prescribed and nursing presccribed interventions.
What happens during the data interpretation and analysis phase of diagnosing?
  • recognization of significant data
  • comparing data to standards
  • recognizing patterns or clusters
  • identifying strengths and problems
  • reaching conclusions
What possible conclusions can be reached while developing a nursing diagnosis?
  • there is no problem
  • there is a possible problem
  • there is an actual or potential nursing diagnosis
  • there is a clinical problem other than a nursing diagnosis
What is the correct way to formulate a nursing diagnosis?
  • Problem: nursing dx; identifies what is unhealthy about pt
  • Etiology: "related to" r/t, cause or etiology of the problem
  • symptoms: "as manifested by" defining characteristics; identifies the subjective and objective data that signal the existence of a problem
What are the steps in the process for data interpretation and analysis
  • Highlight or list relevant data/symptoms (defining characteristics)
  • cluster the symptoms
  • analyze/interpret subjective data
  • choose a nursing diagnosis label that fits the related factors and defining characteristics
What are the benefits of nursing diagnoses?
  • Individualizing of pt care
  • defining the domain of nursing to healthcare administrators, legislators, and providers
  • seeking funding for nursing and reimbursement for nursing services
What are commong sources of error when writing nursing diagnoses?
  • making legally inadvisable statements
  • reversing the clauses
  • identifying enviromental factors rather than patient factors as the problem
  • identifying a pt response that is not necessarily unhealthful
  • having both clauses say the same thing
  • identifying a pt problem that cannot be changed
What are comon sources of error in nursing diagnoses?
  • premature diagnoses based on imcomplete database
  • erroneus diagnoses resulting from inaccurate or faulty database
  • routine diagnoses resulting from failure to tailor data to pt
  • errors of omission
What is done during the planning step of planning and outcome identification?
  • Establish prioritized nursing diagnoses
  • ID and write measureable pt outcomes
  • select evidence based nursing interventions to achieve outcomes
  • communicate the plan of care
How should nursing diagnoses be prioritized?
  • High priority: greatest threat to pt well-being
  • Medium priority: non-threatening diagnoses
  • Low priority: diagnoses not specifically realted to current health problem
What are the levels on Maslow's hierarchy of human needs?
  • physiologic needs
  • safety needs
  • love and belonging needs
  • self-esteem needs
  • self-actualization needs
What does a formal plan of care allow a nurse to do?
  • Individualize care that maximizes outcome achievment
  • set priorities
  • facilitate comunication among nursing personnel and colleagues
  • promote continuity of high-quality, cost effective care
  • corrdinate care
  • evaluate pt response
  • create a record used for evaluation, research, reimbursement, and legal reasons
  • promote nurse's professional development
Who does the inital planning and what occurs?
  • Initial planning is developed by the nurse who performs the nursing history and physical assessment
  • It addresses each problem listed in the prioritized nursing diagnoses
  • Appropriate patient goals and related nursing based evidence are identified
Who conducts ongoing planning and what occurs?
  • Ongoing planning is carried out by any nurse who interacts with the pt
  • the plan is kept up to date
  • new diagnoses may be developed
  • outcomes can be adjusted to reflect reality
  • new outcomes can be added as needed
  • nursing interventions are updated as needed to accomplish pt goals
Who carries out discharge planning? What occurs during discharge planning?
  • The nurse who worked most closely with the pt carries out discharge planning
  • it begins when the pt is admitted for treatment
  • effective use of teaching and counseling skills is necessary to ensure home-care behaviors are performed correctly
What is the difference between long-term and short-term goals?
  • long term goals require a longer period to be achieved and may be used as discharge goals
  • short term goals may be accomplished in a specific period of time
What are the four types of outcomes?
  • cognitive: increase in pt knowledge
  • psychomotor: pt's acheivment of new skills
  • affective: changes in pt values, beliefs, and attitudes
What ate the parts of a measureable outcome?
  • subject
  • verb
  • performance criteria
  • conditions
  • target time
  • eg. pt will demonstrate self monitoring of blood glucose prior to discharge
What are common errors in writing pt outcomes?
  • expressing pt outcomes as nursing interventions
  • using verbs that are not observable or measureable
  • including more than one pt behavior or manifestation in short term outcomes
  • writing vague outcomes
What are the types of nursing interventions?
  • nurse initiated: actions performed by a nurse without a physician's order
  • physician initiated: actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under a Dr.'s orders
  • collaborative: treatments carried out by a nurse initiated by other providers
What actions are performed in nurse-initiated interventions?
  • monitor health status
  • reduce risk
  • resolve, prevent, or manage a problem
  • facilitate independence or assist with ADLs
  • promote optimum sense of physical, psychological and spiritual well being
What are some types of institutional care plans?
  • Kardex plans of care
  • computerized plans of care
  • case management plans of care
  • clinical pathways, care maps
  • student plans of care
  • concept map care plan
what are some problems related to outcome identification planning?
  • failure to involve pt
  • insufficient data collection
  • nursing dx developed from inaccurate or insufficient data
  • outcomes stated too broadly
  • outcomes derived from poorly developed nursing dx
  • failure to write nursing orders clearly
  • nursing orders that do not solve problems
  • failure to update the plan of care
What are the steps for implementing a care plan?
  • organize resources
  • anticipate unexpected outcomes/situations
  • promote self care: teaching, counseling, advocacy
  • assist pts to meet health outcomes
  • document your interventions
  • delegate appropriately
What are some common reasons for noncompliance?
  • lack of family support
  • lack of understanding about the benefits
  • low value attached to outcomes
  • adverse physical or emotional effects of treatment
  • inability to afford treatment
Describe what happens during the evaluating step.
  • Evaluation is an on-going process
  • Identify evaluative criteria and standards
  • collect data
  • interpret and summarize findings
  • document judgement
  • terminate, continue, or modify the plan
Evaluating outcomes
  • Cognitive: asking pt to repeat information or apply new knowledge
  • psychomotor: asking pt to demonstrate new skill
  • affective: observing pt behavior and conversation
  • physiologic: using physical assesment skill to collect and compare data
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