Chapter 5 - Nursing Process and Critical Thinking

  1. American Nurses Association (ANA) defines nursing is
    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
  2. nursing process
    a systemic method by which nurses plan and provide care for patients
  3. steps of nursing process
    • 1. identify patient problems and potential problems
    • 2. plan, deliver, and evaluate nursing care in an orderly, scientific manner.
  4. 6 dynamic and interrelated phases
    assessment, diagnosis, outcomes indeitification, planning, implementation, and evaluation
  5. assessment
    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
  6. a complete assessment process?
    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
  7. What does a complete assessment involve?
    a review and physical exmination of all body systems (musuloskeletal, respiratory, gastrointestinal)
  8. What does assessment include?
    cognitive, psychological, emotional, cultural, and spiriritual components and is appropriate for a patient with a stable condition who is not in acute distress
  9. What is focused assement used for?
    gathering information about a specific health problem, and is advisable when the patient is critically ill, disoriented, or unable to respond
  10. cue
    a piece or pieces of data that often indicates that an actual or potential problme has occurred or will occur
  11. subjective data
    information that is provided by the patient

    ex: nausea and descriptions of pain, fatigue, and anxiety
  12. objective data
    observable and measurable signs

    ex: LPN/LVN is able to observe capillary refill, measure a patient's blood pressure, and observe and measure edema
  13. Who is primary source of data and secondary source of data?
    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
  14. 2 methods of data collection
    interview and physical examination
  15. biographic data
    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.
  16. 1st method of data collection
    interview - to obtain information about the patient's health history
  17. 2nd method of data collectiopn
    physical examination - guided by subjective data provided by the patient
  18. A head to toe format
    provides a systematic approach that helps avoid omission of important data
  19. database
    a large store or bank of information
  20. Where does data obtain from?
    the health history, physical examination, and related diagnostic produces
  21. purpose of data clustering?
    to identify patterns that assist with the idenfitication of nursing diagnoses
  22. example of data clustering
    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
  23. diagnose
    identify the type of cause of a health condition
  24. ANA defines diagnosis as
    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
  25. RN is responsible for
    analyzing and interpreting data to identify health problems
  26. nursing diagnosis
    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
  27. What does nursing diagnosis provide?
    the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability
  28. When nurses submit nursing diagnoses, 4 component are addressed:
    • 1) nursing diagnosis title or label
    • 2) definition of the title or label
    • 3) contributing, etiologic, or related factors
    • 4) defining characteristics
  29. definition
    presents a clear, precise description of the problem
  30. ability
    power or capacity to perform actions
  31. anticipatory
    to realize beforehand, to foresee
  32. balance
    state of equilibrium
  33. compromised
    made vulnerable to threat
  34. decreased
    lessened; lesser in size, amount or degree
  35. defensive
    used or intended to protect from a perceived threat
  36. deficient
    inadequate in amount, quality, or degree; not sufficient; incomplete
  37. delayed
    postponed, impeded, or retarded
  38. depleted
    emptied wholly or in part, exhausted of
  39. disabling
    making unable or unfit, incapacitating
  40. disorganized
    characterized by destruction of the systematic arrangement
  41. disproportionate
    not consistent with a standard
  42. distrubed
    agitated or interrupted, interfered with
  43. dysfunctional
    abnormal, incomplete functioning
  44. effective
    producing the intended or expected effect
  45. excessive
    characterized by an amount of quantity that is greater than necessary, desirable, or useful
  46. functional
    normal complete functioning
  47. imbalanced
    state of disequilibrium
  48. impaired
    made worse, weakened, damaged, reduced, deteriorated
  49. inability
    incapacity to do or act
  50. increased
    greater in size, amount, or degree
  51. ineffective
    not producing the desired effect
  52. interrupted
    characterized by a break in continuity or uniformity
  53. low
    containing less than the norm
  54. organized
    formed into a systematic arrangement
  55. perceived
    having been brough into awareness by means of the senses; characterized by assignment of meaning
  56. readiness for enhanced (for use with wellness diagnosis)
    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)
  57. situational
    related to particular cirumstances
  58. total
    complete, to the greatest extent or degree
  59. defining characteristics
    the clinical cues, signs, and symptoms that furnish evidence that the problem exists
  60. 4 main types of nursing diagnoses
    actual, risk, syndrome, and health promotion
  61. actual nursing diagnosis
    a clinical judgment about human experience/ responses to health conditions/ life processes that exist in an individual, family, or community
  62. actual diagnosis of three-part statement
    • 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
  63. risk nursing diagnosis
    a clinical judgment that describes human responses to health conditions/ life processes that may develop in a vulnerable individual/ family/ community
  64. risk diagnosis of two-part statments
    • 1) the nursing diagnosis label from the NANDA-I list
    • 2) the risk factors
  65. syndrome nursing diagnosis
    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
  66. wellness nursing diagnosis
    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
  67. readiness for enhanced are used in
    wellness nursing diagnosis

    ex: readiness for enhanced self-health managment
  68. collaborative problems
    health-related problems that the nurse anticipates based on the condition or diagnosis of a patient
  69. medical diagnosis
    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
  70. the outcomes statement indicates
    the degree of wellness desired, expected, or possible for the patient to achieve and contains a patient goal statement
  71. patient outcome statement provides
    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
  72. desired patient outcome statements serve 2 functions:
    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
  73. goal
    the purpose to which an effort is directed
  74. outcome
    description of the specific measurable behavior that the patient will be able to exhibit after the nursing interventions
  75. planning
    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
  76. nursing interventions
    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
  77. physician-prescribed interventions
    those actions ordered by a physician for a nurse or other health care professional to perform
  78. nurse-prescribed interventions
    any actions that a nurse is legally able to order or begin independently
  79. implementation
    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
  80. evaluation
    a determination made about the extent to which the established outcomes have been achieved
Card Set
Chapter 5 - Nursing Process and Critical Thinking
Unitek College, LVN