Nursing Process

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  1. What is a process?
    It is a series of steps or components leading to achievement of a goal.
  2. Characteristics of a process:
    • Purpose
    • Organization
    • Creativity
    • Interaction
    • Scientific
    • Tools
  3. A process is a continuous progression from one point to another to ahcieve a specific goal.
  4. A system is made of separate parts or elements. The parts rely on one another and are interrelated have a common purpose and together form a whole.
    Systems Theory
  5. A system has a specific goal.

    The content is the product and info obtained from the system.
  6. 3 Components of a System:
    • Input
    • Output
    • Feedback
  7. Which type of system:

    Interacts with it's environment

    Exchange of info between the system and the environment
    Open system
  8. Which type of system:

    Does not interact with the environment

    No exchange of info
    Closed system
  9. Nursing Process as a system:
    • Purpose - provide systematic, individualized and appropriate care to client
    • Process - 5 components of the Nursing Process
    • Content - Info is obtained and used from each component
  10. The Nursing Process is a ___ system.

    Because it interacts with it's environment continually changing as the client's needs change.
  11. Nursing Process as a system:
    • Input - assessment and from nursing interventions
    • Output - evaluation component
    • Feedback - evaluation component returned and reassessment occurs on basis of client's health care needs.
  12. Theoretical approach to the Nursing Process:

    Problem solving method
    • Foundation for the nursing process
    • A specific method for obtaining a solution to a problem
    • Is a 6 step process
  13. 6 Step Problem Solving Method:
    • 1.) Encountering a problem
    • 2.) Collecting data
    • 3.) Identifying exact nature of the problem
    • 4.) Determining a plan of action
    • 5.) Carrying out the plan
    • 6.) Evaluating the plan and the new situation
  14. What does the Nursing Process provide us with?
    • Organized framework
    • Goal
    • Tool
    • Independent nursing action
    • Promotion
    • Focus
    • Creativity
  15. A method for organizing and delivering nursing care.

    Provides the organizational structure and framework for nursing care, yet it is creative and flexible enough to be used in a variety of settings.
    Nursing Process
  16. Is an organized systematic method of giving individualized nursing care that focuses upon identifying and treating unique responses of individuals or groups to actual or potential alteration in health.
    Nursing Process
  17. Purpose of the Nursing Process:
    • Identifies problems
    • Establishes line of communication and establishes a database
    • Delivers method to give nursing care and provides continuity of nursing care
  18. The Nursing Process organization has 5 components that are interrelated.

    *These 5 components are:
    • 1.) Assessment
    • 2.) Nursing diagnosis
    • 3.) Planning
    • 4.) Implementation
    • 5.) Evaluation
  19. Purpose:

    To gather, verify and communicate data.
    Establish the data base
  20. Steps:

    Collecting nursing health history
    Perform physical exam
    Collect lab data
  21. Purpose:

    To identify health care problems and needs of the client.
    To formulate nursing diagnostic statement.
    Nursing diagnosis
  22. Steps:

    Interpret, cluster and validate data
    Formulate nursing diagnostic statement
    Nursing Diagnosis
  23. Purpose:

    Identify client goals
    Determine priorities
    Design nursing strategies
    Determine outcome criteria
  24. Steps:

    Identify client goals
    Select nursing actions
    Delegate actions
    Write NCP (nursing care plan)
  25. Purpose:

    Complete nursing actions necessary for accomplishing plan
  26. Steps:

    Perform nursing actions
    Review and modify existing care plan
  27. Purpose:

    Determine the extent to which goal of care has been accomplished
  28. Steps:

    Evaluate according to the established evaluation criteria
    Compare client response to criteria
    Analyze reasons for results and conclusions
  29. Goals of Nursing:
    • Promote, maintain or restore health
    • Enable individuals to manage their own health
    • Provide nursing care
  30. History of Nursing Process:
    • Introduced in 1950, was a 3 step process:
    • assessment
    • planning
    • evaluation
  31. History of Nursing Process:
    • 1976 - 5 step process
    • Classification of nursing diagnoses
    • Advanced the profession
    • Focus of nursing care is established through the nursing care plan
    • Specific nursing responsibility defined
  32. Nursing autonomy and accountability are enhanced through the identification of health care problems within the domain of nursing practice.
  33. Assessment

    Data collection and Data organization
  34. What the client actually SAYS
    May not be validated
    May not be factual
    Subjective Data
  35. Based on what you see, hear, smell and feel.
    Objective Data
  36. Initial assessment
    Includes objective and subjective data
    • Screening Assessment
    • Baseline assessment
  37. Assessment on a specific area
    Focused assessment
  38. Subjective statements and objective data
    Something you see or hear
  39. Always subjective
    Influenced by nurses knowledge
  40. Assessment is an on-going continuous process it occurs throughout each phase of the nursing process.
  41. Data Organization:

    • Maslow's Heirarchy
    • Nursing Diagnosis
  42. Nursing Diagnosis
    States the actual or possible problems.
  43. Three Steps in the area:
    • 1.) Analysis
    • 2.) Identification (actual or risk diagnosis)
    • 3.) Statements
  44. Problems identified are those the nurse is licensed and competent to treat.
  45. Identification of a disease based on physical signs, symptoms, history, lab tests and procedures.
    Medical diagnosis
  46. Derived from the physiological psychological sociocultural developmental and spiritual dimensions.
    Medical diagnosis
  47. Goals are to identify and cure the disease.

    The focus is curative.
    Medical diagnosis
  48. Identifies health are needs.
    Present level of health
    Response to a disease
    Nursing diagnosis
  49. Goals and objectives are to identify health problems and develop a plan of care.

    Focus is to help the client reach a maximal level of wellness.
    Nursing diagnosis
  50. Advantage of Nursing Diagnosis:
    • Facilitates communication
    • Focus for quality assurance and peer review.
  51. Limitation of Nursing Diagnosis:
    Incomplete Taxonomy
  52. NANDA (North American Nursing Dx Associates) does what:
    Approve nursing diagnosis
  53. Statement of actual or possible problem that requires nursing intervention to resolve or less or prevent.
    Nursing diagnosis
  54. PES format includes:
    • Problem
    • Etiology
    • Signs and symptoms
  55. Ask yourself three questions when making a nursing diagnosis:
    • What is the problem?
    • What is causing the problem?
    • How do you know the problem exists?
  56. Problem = nursing diagnosis
    Etiology = what is causing the problem?
    Signs & Symptoms = always supports the nursing diagnosis it NEVER supports the etiology

    Avoid using medical diagnosis as etiology.
  57. Do not use for a newly diagnosed paraplegic

    no: impaired walking
    yes: impaired mobility
  58. Nursing diagnosis should be simple, brie, specific and based on collected data.
  59. Nursing diagnosis statement:
    • Actual problem
    • related to

    • Contributing Factors (etiology)
    • as shown by

    • Defining characteristics
    • as manifested by

    Do not say "due to"
  60. May use "of unknown etiology"

    Acute pain of unknown etiology...
  61. Example

    Impaired walking (nursing diagnosis
    Related to post op status (etiology)
    As shown by requiring physical support during ambulation (signs and symptoms)
  62. Example:

    Acute pain related to fractures, trauma and immobility as manifested by client reporting pain of 6 on a pain scale. BP 120/76, P 100, R 30 & moaning.
  63. Priorities:
    • High
    • Medium
    • Low
  64. Basic needs
    Psychological and Physiological
    HIGH priority
  65. Intermediate and Non life threatening
    Medium priority
  66. Not directly related to specific illness or disease process
    Low priority
  67. Acute pain related to surgical incision as manifested by client stating the incision hurts.
    • Etiology? surgical incision
    • Problem? acute pain
    • Supporting evidence? client states incision hurts
    • Priority? 1 week - medium; 6 hr post op - high
  68. Two part statement

    Risk of problem developing and probable cause or etiology

    There are NO signs and symptoms!
    Risk diagnosis
  69. Incorrect statements of the nursing diagnosis:
    • Nursing diagnosis stated as a medical diagnosis - such as an MI
    • Use of medical terminology to describe the cause (decrease cardiac output r/t MI)
  70. Common Errors in writing nursing diagnosis:
    • Statement may legally inadvisable and may show implications of blame
    • Problem and etiology say the same thing
    • Environmental problems are put into the problem statement
    • Identified problem is not necessarily unhealthy
    • Identified problem cannot be changed
  71. Common errors:
    • Omission
    • Incomplete data
    • Incorrect clustering
    • Incorrect interpretation
    • Commission
    • Diagnosing of non existent problems
  72. Goals to lessen, prevent or resolve the problem
    A category to develop nursing behaviors/nursing interventions

    3rd step in nursing process.
  73. In planning:
    • Goals are determined
    • Priorities are established
    • Outcomes -something that the client can accomplish that you can measure
    • Nursing care plan
    • Consulting
    • Modifiying care
    • Documentation - document what the outcomes and interventions are
  74. Goals must be specific to patient.
    • Goals must be important to client.
    • What is important to them may not be important to you.
  75. Nursing care plan:
    • Problems
    • Goals for every problem
    • Nursing actions for every goal
    • Projected outcomes
    • Evaluation - how do you know you have accomplished the goal
  76. Purpose of nursing care plan:
    • Documentation - of what is impt to the client
    • Coordination of care
    • Promotion of health and wellness
    • Criteria for evaluation
    • Communication
    • Lower risk of inaccurate care
  77. Nursing care plans also:
    • Identify problems
    • Cost effective (may decrease length of hospital stay)
    • Organization of information
    • Discharge planning
  78. 3 types of Nursing Care Plans:
    • Institutional
    • Standardized
    • Student
  79. Institutionalized care plan:
    Everyone is treated the same, similar medical problems
  80. Standardized care plan:
    Associated with specific medical disease (ex: MI has same basic needs)
  81. Student care plan:
    More specific to the patient, includes all of the patient's problems.
  82. Planning Defined:
    • Setting Priorities
    • Writing goals/objective/outcomes
    • Planning nursing actions must be specific to goals/objectives.
  83. Determining goals:
    • Achievement of maximal level of wellness
    • Involve client, family, SO
    • (ex: wife will learn how to prepare low fat meals)
  84. Projected outcomes of planning:
    • Determination if goal has been met or not
    • Measurable behaviors
    • Criteria used for evaluation
    • Realistic
    • Time frame
  85. Components of Goal Statement:
    • Subject/Noun (who)
    • Verb (will do)
    • Criteria/Task (what)
    • Condition (when)

    Who will do what when?
  86. Intellectual knowledge
    Cognitive domain

  87. Client will verbalize understanding of decreased caloric intake.
    Cognitive domain
  88. Manipulation and motor skills
    Psychomotor domain
  89. Client will walk 10 feet without assistance.
    Psychomotor domain
  90. Value, judgements, and emotion.
    Affective domain
  91. Client will express feelings about lonliness.
    Affective domain
  92. Pain at cellular level; pain at incision site
    Psychomotor domain
  93. Pain due to grief or emotions
    Affective domain
  94. Objective/Goal states:
    • What the client will accomplish
    • Outcome criteria
    • Realistic time frame to accomplish the objective
    • Realist for the nurse's level of skill
    • Congruent with and supportive of medical regime
    • Important and valued b the client, nurses and physicians.

    • Must be written behaviorally.
    • (client will do something specific themselves: state something, perform a task)
  95. 3 Goals/Objective Categories:
    • Prevention
    • Rehab
    • Education
  96. Prevents problem from occurring
  97. Prevents the problem
  98. Teaches the patient about the problem.
  99. Nursing diagnosis:
    Impaired skin integrity related to prolonged bed rest and immobility as evident by a 3 x 2stage II decub ulcer on right buttocks.

    HIGH priority
  100. Planning:

    The client's decubitus ulcer on right buttock will decrease to 2 cm x 1 cm by 2/28/2012.
    • psychomotor (cellular level)
    • rehab
  101. The client will understand the importance of repositioning self to prevent further skin breakdown by 2/28/2012 as evident by verbalization
    • cognitive
    • education
  102. Client's decubitus ulcer on right buttocks will be completely healed as evidenced by no redness, drainage or bread in epidermal layer by 2/28/2012
    • psychomotor
    • rehab
  103. Client will experience no additional skin break down by 2/28/12
    • psychomotor
    • prevention
  104. Evaluation Outcome Criteria (EOC):

    When you have a BROAD goal statement EOC's may be needed for measurement.

    Client will experience decreased pain experience by 2/28/12 as evidence by:

    1. Decreased requests for pain med, requests for pain med at 8 hour intervals instead of 6 hour intervals.

    2. Correct use of muscle relaxation techniques

    3. Verbalization of decreased pain on a pain scale of 1-10 with 10 being the most severe pain.

    • psychomotor
    • rehab
  105. Client will perform quad exercises every 1 hour while awake.

    • psychomotor
    • rehab/prevention
  106. Client will appreciate the need to ambulate.
    • Incorrect

    • Client will verbalize the need to ambulate.

    • affective
    • education/prevention/rehab
  107. Mother will be instructed on proper infant care.
    Incorrect this is an nursing intervention.
  108. Wife will list 10 foods high in Na by the end of the week.

    • cognitive
    • educational
  109. Weight reduction group will attend classes weekly.

    • psychomotor
    • education/rehab/prevention
  110. Client will understand major purpose of his meds 2 days prior to expected discharge by 2/28/12
    • Incorrect, you cannot measure "understand"
    • Client will verbalize, instead.

  111. Client will ambulate by 2/28/12.

  112. Client will write his menu for a week by 2/28/12

    • Cognitive
    • Educational
  113. Common Mistakes in writing Goals/Objectives:
    • Written in terms of nursing actions rather than client actions.
    • Cannot be observed or measured through one of the senses.
    • Task not specific to the individual client.
  114. Improve & more specific goal statements:
    Client will state 1 major purpose for each of his four meds 2 days prior to expected discharge of 2/28/12

    Client will walk without assistance from this room to the nurses station by 2/28/12

    Client will select one food from each of the four basic food groups for his dinner by 2/28/12
  115. Planning nursing actions:
    Nursing strategies are developed to achieve a client goal.

    • Based upon client center goals
    • Determine priorities
    • Specify nursing actions
    • Use collaborative approach
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Nursing Process
Nursing Process
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