The Nursing Process/ Lect. 2

ID the five components of the nursing process in order

assessment, diagnosis or analysis, outcome identification/planning, implementation, evaluation

What are things to condor during the nursing process?

ALWAYS include pt.

can go forward or backwards/ overlap

ID actual or potential problems

Conditions can change rapidly

What is the most valuable and important step in the nursing process?

Assessment

What are the four different ways for data collection during assessment?

observation using 5 senses, interview pt., physical assessments (to confirm or advance info received from pt.) and investigation (review med. history/ consult w. specialist)

What are the 5 different types of physical assessments?

Baseline, initial, focused, emergency, time-lapsed

This type of physical assessment involves an examination of a certain area/ only one of the body system.

Focused assessment

This type of physical assessment is the pts. "normal" and is gathered from pts. regularly visited pcp

Baseline assessment

This type of physical assessment is the first assessment with pt.

initial assessment

This assessment is involves an emergency situation such as a fall, chest pain, or blocked airways

Emergency assessment

This type of assessment monitors the progression or regression of pt. status from initial assessment to present, it is used to compare and contrast over a period of time

Time-lapsed assessment

T/F: Physical Assessments are very seldom performed in a head- to-toe manner

False!

What are the two types of data collection?

Objective or overt data - stuff that can be measured or seen

Subjective or covert data- info. the pt. is telling you

During which step of the nursing process are you interpreting and analyzing data that has been gathered

Diagnosis/Analysis

ID and explain the three different types of healthcare diagnosis

Nursing Diagnosis- can treat WITHOUT a medical order

Medical Diagnosis- physician needs to write out order

Collaborative problems- using nursing and physician prescribed orders

What is an actual problem

an occurring problem

What is the nursing diagnosis formulation for an actual problem

Problem- NANDA label

Etiology- what is causing the problem

Signs/Symptoms- defining characteristics

T/F: The below statement is an appropriate nursing diagnosis:

"Impaired physical mobility b/c lower right tibial fracture as presented by pain being >8

False, while the problem is a NANDA label the wording following it is not correct. "r/t" not "b/c" the etiology cannot be a medical diagnosis such as a tibial fracture. the symptoms/signs should be introduced with "AMB" or as manifested by

Come up with a 3 part nursing diagnosis

(NANDA problem) r/t (etiology) AMB (sign/symptoms)

What is a potential problem

a risk

What is the nursing diagnosis formula for a potential problem

Problem- NANDA label, must include "risk for"

Etiology- what is risking the problem

When formulating a nursing care plan, the goal must correct what

the signs/symptoms in the nurse Dx.

T/F: When identifying outcomes/ planning, any goal planned to take a week or longer is considered a short term goal

False, considered long term

What must a goal statement start with?

"pt./client will...."

Which stage in the nursing process deals with the RN working with the pt. to formulate a goal(s)

Outcome Identification/Planning

This is the "action step" of the nursing process

implementation

This stage involves examining/ reflecting on how well, if even, the pt. met the goal(s) planned

Evaluation

What are the three domains of learning

cognitive, affective, psychomotor

T/F: If a goal is not met you should give up and let the pt. figure it out

False, delete or modify nursing dx.

make the outcome statement more realistic

Increase complexity

Adjust criteria in the goal statement

Change the nursing intervention(s)