1 The Nursing Process

Flashcards based on lecture notes about the nursing process.

What are the 6 steps of the Nursing Process?

Assessment, Diagnosis, Outcomes Identification, Planning, Implementation, and Evaluation.

How is the nursing process defined?

It’s a critical thinking model based on a systematic approach to patient-centered care that helps to ensure safe, effective and evidence based care.

Describe the Patient-centered aspect of the Nursing Process.

Requires care respectful of and responsive to the individual patient’s needs, preferences, and values.

Describe the Interpersonal aspect of the Nursing Process.

Provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals.

Describe the Collaborative aspect of the Nursing Process.

Promoting open communication, mutual respect, and shared decision making with nursing and interprofessional teams.

Describe dynamic and cyclical aspect of the Nursing Process.

It’s a constant process which each phase interacts with and is influenced by other phases.

What are the types of data gathered during a nursing assessment?

Subjective, Objective, Verbal, and Non-Verbal Data

Give examples of Subjective Data.

Information provided by the patient (e.g., pain levels, symptoms).

Give examples of Objective Data.

Observable and measurable data (e.g., vital signs, lab results), physical assessment.

What are the four Physical Assessment Techniques?

Inspection, Palpation, Percussion, and Auscultation

What does Inspection involve?

Using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings.

What does Palpation involve?

Using parts of the hand to touch and feel for characteristics such as texture, temperature, moisture, mobility, consistency, pulses, size, shape, and tenderness.

What does Percussion involve?

Tapping body parts to produce sound waves to assess underlying structures.

What does Auscultation involve?

Using a stethoscope to listen for heart sounds, blood movement, bowel and lung sounds.

What are Primary sources of information in Nursing Assessment?

Patient interview, past medical history, current complaints

What are Secondary sources of information in Nursing Assessment?

Physical examination, patient observation, family/caregiver interview, medical chart review, diagnostic tests

What are Tertiary sources of information in Nursing Assessment?

Textbooks, databases, journals, academic literature

What is the goal of Nursing Assessment?

Develop a comprehensive understanding of the patient’s health status, risks, & needs.

What does the SAMPLE mnemonic stand for in Nursing Assessment?

Signs & Symptoms, Allergies, Medications, Past medical history, Last meal, Events leading to patient presentation

What is a Nursing Diagnosis?

A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability to that response, by an individual, family, group, or community.

What is the difference between a Medical Diagnosis and a Nursing Diagnosis?

A medical diagnosis focuses on disease and illness, while a nursing diagnosis focuses on the harmful responses to said diagnosis and needs of the patient.

What are the Four Types of Nursing Diagnoses?

Problem-Focused, Risk, Health Promotion, and Syndrome

Describe Problem-Focused Nursing Diagnosis.

Addresses a current finding upon assessment, including signs, symptoms, and patient health history.

Describe Risk-Based Diagnosis.

Clinical judgment that the patient is at risk for health consequences if preventative measures are not implemented, focusing on preventing undesirable health outcomes.

Describe Health Promotion Based Diagnosis.

Requires that the individual/family/community is functioning effectively but has an opportunity to increase well-being, aiming to improve and actualize health potential.

Describe Syndrome-Based Diagnosis.

A clinical judgment concerning two or more concurrent nursing diagnoses that are related and can be treated using similar interventions.

What is the P-E-S format used for in nursing?

Problem-Focused Diagnosis
Problem (Diagnostic Label) + Etiology (Cause or Related Factors) + Signs/Symptoms (Defining Characteristics)

What is a Risk-Focused Diagnosis composed of?

Risk (Diagnostic Label) + Risk Factors

What is a Health Promotion-Based Diagnosis composed of?

Health Promotion (Diagnostic Label) + Signs & Symptoms (Defining Characteristics)

What two things compose a Syndrome Based Diagnosis?

Syndrome (Diagnostic Label) + 2 or more supporting Nursing Diagnoses

What is the Planning phase of the nursing process?

Developing care plans to provide a course of action tailored to patient’s needs and desired outcomes, enhancing communication, documentation, and continuity of care.

What should Nursing Care Plans include?

use all parts of the Nursing Process

What is required of a care plan?

critical, holistic thinking

How can you document effectively?

Assessment, efficacy of interventions, goals, education given. "If you did not document, it didn’t happen!"

What are the Basic Physiological Needs according to Maslow?

Nutrition, elimination, airway/breathing/circulation (ABC’s) sleep, shelter

What are the Safety and Security needs according to Maslow?

Injury prevention, trust and safety (therapeutic relationship), patient education & advocacy

What are aspects of the Love and Belonging level on Maslow's Hierarchy of Needs?

Supportive relationships, reducing isolation, minimizing bullying, active listening, therapeutic communication

What are aspects of the Self-Esteem level on Maslow's Hierarchy of Needs?

Acceptance and recognition, personal achievement, sense of control or empowerment, positive body image

What are aspects of the Self-Actualization level on Maslow's Hierarchy of Needs?

Spiritual growth, achieving one’s potential

What are the 5 criteria of a SMART goal?

Specific, Measurable, Achievable, Relevant, Time-bound

What does the Implementation step include?

Action and carrying out the nursing interventions laid out in the nursing care plan.

What are the six aspects of the evaluation phase of the nursing proccess?

Collecting data, Comparing collected data with desired outcomes, Analyzing client’s response to interventions, Identifying successful and not successful treatments, Continuing, modifying, or terminating existing nursing care plan, and Planning ahead-being proactive