The Nursing Process

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The Nursing Process
2010-10-19 19:01:46
nursing nurs200

NURS 200 - The Nursing Process - Ch 17, 18, 19, 20
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  1. What are evaluative measures? How are they different from assessment measures?
    Evaluative measures are skills and techniques used to assess if the patient's known problems have improved, worsened, or otherwise changed.

    Assessment measures are performed at the point of care when problems are being identified. Evaluative measures are performed at the point of care when changes to the problem are identified.
  2. An intervention is developed in which step of the nursing process?

    Interventions may be across disciplines, and are used to attain goals specific to the nursing diagnosis.
  3. What are the guidelines for writing goals and expected outcomes? (planning step)
    • Focus on the client
    • Address only one goal or outcome
    • Develop outcomes that are observable
    • Write outcomes that can be measured
    • Clearly state time frame
    • Consult with the client
    • Be realistic
  4. What are the 3 types of nursing interventions?
    1. Independent nursing interventions (aka nurse-initiated interventions) - actions that a nurse initiates without direction from a physician or other healthcare professional.

    2. Dependent nursing interventions (aka physician-initiated interventions) - actions that require an order from a physician or another healthcare professional

    3. Collaborative interventions - therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.
  5. A nurse begins and completes all actions that are necessary in order for the patient to achieve their goals and expected outcomes. What step does this describe?
  6. What happens during the implementation process?
    • Reassessing the client
    • Organizing resources and care delivery
    • Anticipating/preventing complications
    • Communicating nursing interventions
  7. What are the 3 implementation skills needed for direct and indirect nursing interventions?
    • Cognitive skills - involve application of critical thinking
    • Interpersonal skills - involves devloping a trusting relationship with the pt, expressing a level of caring, and communicating clearly with the pt & their family
    • Psychomotor skills - involves the integration of cognitive and motor activities. (ex: you must understand anatomy (cognitive) and practice good coordination & precision (motor) when giving an injection.)
  8. In what step do you measure whether the patient has made improvement?
    Evaluation (final step) - measures the pt's response to nursing actions and the client's progress toward achieving goals.
  9. What is an expected outcome?
    the specific, step-by-step objective that leads to attainment of the goal and the resolution of the etiology for the nursing diagnosis.
  10. Short-term goal vs. long-term goal?
    Short term goal - objective behavior or response that is expected to be achieved in a short period of time, usually less than a week. (ex: Client's level of comfort will improve before surgery)

    Long term goal - objective behavior or response that is expected to be achieved over a longer period of time, usually over weeks or months. (ex: Patient will be tobacco-free within 60 days)
  11. What is a client-centered goal?
    A specific and measurable behavior or response that reflects the client's highest possible level of wellness and independence in function
  12. What are four things you do when designing nursing care for your client? (planning stage)
    • Set priorities
    • Determine goals
    • Develop expected outcomes
    • Formulate a plan of care
  13. How can you avoid errors in the diagnostic process?
    • Avoid legally in advisable statements
    • Identify the problem and etiology
    • Identify only one client problem in the diagnostic statement
  14. When do errors most often occur during the nursing diagnosis step?
    During data collection, data clustering, data interpretation, and statement of the nurs. diag.
  15. What are the 4 types of nursing diagnoses?
    • Actual nursing diagnosis
    • Risk nursing diagnosis
    • Health Promotion nursing diagnosis
    • Wellness nursing diagnosis
  16. How can you differentiate nursing diagnoses from collaborative problems?
    • Nursing diagnosis - the nurse can legally order the primary interventions to achieve the goal for the pt
    • Collaborative problem - nursing interventions AND medical interventions are needed to achieve the goal for the pt
  17. What is a medical diagnosis?
    the indentification of a disease condition based on a specific evaluation of physical signs, symptoms, patient's medical history, and the results of diagnostic tests and procedures.
  18. What is a NANDA diagnosis?
    Standard nursing diagnostic statements endorsed by the North American Nursing Diagnosis Association
  19. What are collaborative problems?
    Actual or potential physiological complication that nurses monitor to detect the onset of changes in a client's status
  20. What is a nursing diagnosis?
    • Identification of specific client responses to health care problems
    • Clinical judgment about individual, family, or community responses to actual and potential health problems or life processes.
  21. What does it mean to validate data?
    Compare it to other records to determine data accuracy
  22. Difference between subjective and objective data?
    • Subjective - what the pt tells you/ what you cannot physically see or assess yourself
    • Objective - an assessment you can make during a physical exam
  23. Difference between a primary source and a secondary source?
    • Primary source - the patient
    • Secondary source - the pt's family, records, physician, etc.
  24. What does the "evaluate" step entail?
    Determining if goals were met and outcomes achieved
  25. What does the "implement" step entail?
    Performing the nursing actions identified in "Planning"
  26. What does the "plan" step entail?
    • Set goals of care and desired outcomes
    • Identify appropriate nursing actions
  27. What does the "diagnose" step entail?
    Identifying the client's problems
  28. What does the "assess" step entail?
    Gathering information about the client's condition
  29. 5 steps of the nursing process?
    • Assess
    • Diagnose
    • Plan
    • Implement
    • Evaluate
  30. What is the main purpose of the nursing process?
    to diagnose, and to treat human responses to actual or potential health problems
  31. What does a nursing care plan decrease the risk of?
    Incomplete, incorrect, or inaccurate care
  32. What is a nursing care plan?
    A written guideline for client care used by all members of the nursing team. It coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care.
  33. What helps a nurse communicate nursing priorities to other health care professionals?
    A nursing care plan
  34. What is a concept map?
    • A gathering of data that is diagramed out to show all they all relate.
    • A visual representation of client problems that show relationships to one another.
    • Groups and categorizes nursing concepts for a holistic view of healthcare needs.
  35. What is a critical pathway?
    A treatment plan that outlines the interventions of each health care discipline, including hour-to-hour care (or daily) of certain procedures, consults, and other activites. It ensures better continuity of care by clearly mapping out the responsibilities of different staff.
  36. How does the delegation of a nursing care plan work?
    The nurse who writes the care plan leaves it for the next shift nurse. She will then work on whatever interventions or tasks are appropriate for that shift.
  37. When would a care plan be modified or discontinued?
    • A care plan is modified if a goal has not been met or if a new problem has arisen. Reassessment of the patient is appropriate and critical thinking must be used to develop new interventions according to the new care plan.
    • A care plan is discontinued if all expected outcomes and goals are met. You must confirm this evaluation with the patient and come to an agreement.
    • Documentation is very important when changing or discontinuing a care plan. Any reassessment data should be recorded. A care plan must be very accurate and current to ensure appropriate continuity of care.