Fundamentals Ch 7: Nursing Process

Q: What is the nursing process?

A: A cyclical, critical thinking process with five steps—assessment, diagnosis, planning, implementation, and evaluation—used to deliver goal-directed, systematic, and client-centered care.It involves continuous assessment and adjustment to improve patient outcomes.

Q: What are the five steps of the nursing process?

• Assessment/data collection

• Analysis/diagnosis

• Planning

• Implementation

• Evaluation

A Apple PIE

Q: What is the purpose of the nursing process?

A: To organize and apply scientific reasoning and the best available evidence to deliver optimal, individualized client care.

Q: What happens during the assessment/data collection step?

A: Nurses collect subjective and objective data using observation, interviews, exams, medical records, diagnostic tests, and collaboration.

Q: What are subjective vs. objective data?

• Subjective: Client's verbal expressions (e.g., "My shoulder really hurts")

• Objective: Nurse’s observations or test results (e.g., grimacing during movement)

Q: What are primary and secondary data sources?

• Primary: The client

• Secondary: Family, friends, caregivers, health professionals, or medical records

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Q: What are nurses expected to do with data during assessment?

A: Validate, interpret, and cluster data. Document clearly, thoroughly, and accurately.

Q: What happens during the analysis/diagnosis step?

A: Nurses interpret collected data, identify health problems or trends, and draw conclusions to guide planning.

Q: What are diagnostic reasoning skills?

A: Comparing data with standards, recognizing patterns or trends, and forming nursing diagnoses.

Q: What happens during the planning phase?

A: Nurses establish priorities, develop goals/outcomes, and identify nursing actions to address the client’s problems.

Q: What is Maslow’s hierarchy used for in nursing?

A: To prioritize client needs during planning—starting from physiological needs up to self-actualization.

Q: What are the three types of planning in nursing?

• Initial planning (on admission)

• Ongoing planning (while providing care)

• Discharge planning (starts at admission)

Q: What is the difference between short-term and long-term goals?

• Short-term goals: Achievable in hours to days

• Long-term goals: Weeks to months, guiding chronic care

Q: What are the types of nursing interventions?

• Independent: Nurse-initiated (e.g., repositioning)

• Dependent: Provider-initiated (e.g., medication order)

• Collaborative: Done with other team members

Q: What is done during the implementation step?

A: Nurses carry out the interventions based on the care plan, prioritize tasks, and document client responses.

Q: What critical thinking skills are used during implementation?

A: Decision-making, priority setting, knowledge application, therapeutic communication, and psychomotor skills.

Q: What is the focus of the evaluation step?

A: Determining if the client met the expected outcomes and if interventions were effective.

Q: What questions are asked during the evaluation phase?

• “Did the client meet the goal?”

• “Were the interventions appropriate and effective?”

• “Do we need to revise the plan?”

Q: What factors can lead to unmet goals?

• Incomplete data

• Unrealistic outcomes

• Poor intervention selection

• Inadequate client time