Chapter 5 - Nursing Process and Critical Thinking

the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advoacy in the care of individuals, families, communities, and population

a systemic method by which nurses plan and provide care for patients

• 1. identify patient problems and potential problems
• 2. plan, deliver, and evaluate nursing care in an orderly, scientific manner.

assessment, diagnosis, outcomes indeitification, planning, implementation, and evaluation

a systematic dynamic process by which the registered nurse, through interaction with the patient, family, groups, communities, populations, and heatlh care providers, collects and analyzes data.

It may include physical, psychological, sociocultural, spiritual, cognitive, funtional abilities, developmental, economic, and lifestyle

the LVN/LPN assists the RN by performing ongoing complete and focused assessments of patients, depending on the facility and scope of practice within a state

a review and physical exmination of all body systems (musuloskeletal, respiratory, gastrointestinal)

cognitive, psychological, emotional, cultural, and spiriritual components and is appropriate for a patient with a stable condition who is not in acute distress

gathering information about a specific health problem, and is advisable when the patient is critically ill, disoriented, or unable to respond

a piece or pieces of data that often indicates that an actual or potential problme has occurred or will occur

information that is provided by the patient

ex: nausea and descriptions of pain, fatigue, and anxiety

observable and measurable signs

ex: LPN/LVN is able to observe capillary refill, measure a patient's blood pressure, and observe and measure edema

1st: patient

2nd: family members, significant others, medical records, diagnostic procedures, and previous nursing progress notes, health team professionals (health care providers, nurses, dietitians, respiratory and physical therapists, and others

interview and physical examination

provide information about the facts or events in a person's life

Additional information collected includes the reason the patient is seeking health care, a history of the present illness, the health history, and the family history.

interview - to obtain information about the patient's health history

physical examination - guided by subjective data provided by the patient

provides a systematic approach that helps avoid omission of important data

a large store or bank of information

the health history, physical examination, and related diagnostic produces

to identify patterns that assist with the idenfitication of nursing diagnoses

urine loss associated with physical exertion and urine loss associated with increased abdominal pressure are cue for the nursing diagnosis of stress urinary incontinence

abnormal blood pressure and heart rate response to activity, exertional dyspnea, verbal report of fatigue or weakness are cues for the nursing diagnosis of activity intolerance

identify the type of cause of a health condition

a clinical judgment about the client's response to actual or potential health conditions or needs

provides the basis for determination of a plan of care to achieve expected outcomes

analyzing and interpreting data to identify health problems

a type of health problem that can be identified

a clinical judgment about actual or potential individual, family, or community responses to health problems/ life processes

the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability

• 1) nursing diagnosis title or label
• 2) definition of the title or label
• 3) contributing, etiologic, or related factors
• 4) defining characteristics

presents a clear, precise description of the problem

power or capacity to perform actions

to realize beforehand, to foresee

state of equilibrium

made vulnerable to threat

lessened; lesser in size, amount or degree

used or intended to protect from a perceived threat

inadequate in amount, quality, or degree; not sufficient; incomplete

postponed, impeded, or retarded

emptied wholly or in part, exhausted of

making unable or unfit, incapacitating

characterized by destruction of the systematic arrangement

not consistent with a standard

agitated or interrupted, interfered with

abnormal, incomplete functioning

producing the intended or expected effect

characterized by an amount of quantity that is greater than necessary, desirable, or useful

normal complete functioning

state of disequilibrium

made worse, weakened, damaged, reduced, deteriorated

incapacity to do or act

greater in size, amount, or degree

not producing the desired effect

characterized by a break in continuity or uniformity

containing less than the norm

formed into a systematic arrangement

having been brough into awareness by means of the senses; characterized by assignment of meaning

to make greater; to increase in quality, to attain something more desired (transition from a specific level of wellness to a higher level of wellness)

related to particular cirumstances

complete, to the greatest extent or degree

the clinical cues, signs, and symptoms that furnish evidence that the problem exists

actual, risk, syndrome, and health promotion

a clinical judgment about human experience/ responses to health conditions/ life processes that exist in an individual, family, or community

• 1) the nursing diagnosis label from the NANDA-I list
• 2) the contributing, etiologic, or related factor
• 3) the specific cues, signs, and symptoms from the patient's assessment

a clinical judgment that describes human responses to health conditions/ life processes that may develop in a vulnerable individual/ family/ community

• 1) the nursing diagnosis label from the NANDA-I list
• 2) the risk factors

a clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions

usually written as one-part statements

a clinical judgment about a person's, family's or community's motivation and desire to increase wellbeing and actualize human health potential as expressed in the readiness to enhance specific health behaviors, and can be used in any health state

written as a one-part statement

wellness nursing diagnosis

ex: readiness for enhanced self-health managment

health-related problems that the nurse anticipates based on the condition or diagnosis of a patient

the identification of a disease or condition with evaluation of physical signs, symptoms, patient interview, laboratory tests, diagnostic procedures, review of medical records, and patient history

the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement

a description of the specific measurable behavior (outcome criteria) that the patient will be able to exhibit in a given time frame after the interventions

1st, they guide t he selection of nursing interventions. Nursing interventions are selected to promote the achievement of  the desired outcome

2nd, the outcome statement establishes the measuring standard that is used to evaluate the effectiveness of the nursing interventions

the purpose to which an effort is directed

description of the specific measurable behavior that the patient will be able to exhibit after the nursing interventions

designed for the achievement of the goals of care for an individual patient, as established in accessing and analyzing

It includes developing and modifying a care plan for the patient, cooperating with other personnel, and recording relevant information

those activites that promote the achievement of the desired patient outcome

it includes activites that the nurse selects, in partnership with the patient, to resolve a nursing diagnosis, monitor for the development of a risk problem, or carry out physician orders

those actions ordered by a physician for a nurse or other health care professional to perform

any actions that a nurse is legally able to order or begin independently

ongoing activities of data collection, prioritization, and performance of nursing intervention and documentation

it includes activitives such as teaching, monitoring, providing, counseling, delegating, and coordinating

a determination made about the extent to which the established outcomes have been achieved