unit 11 the nursing process

What is the nursing process?

A problem-solving and decision-making framework used to plan nursing care.

What are the five steps of the nursing process?

Assessment, Analysis, Planning, Implementation, Evaluation.

What is the purpose of the nursing process?

To guide patient care and help identify and address patient problems.

What is the LVN's role in the nursing process?

Collect data, monitor patient progress, contribute to care planning, implement interventions, and evaluate care delivered.

Who interprets assessment data and makes the analysis?

The RN.

Who creates the nursing care plan?

The RN.

What is the LVN's role in care planning?

The LVN contributes to the patient's care plan.

What is the assessment phase?

Collecting, organizing, validating, and recording data about the patient's current health.

What are the main sources of assessment data?

The patient, family, healthcare team, medical records, and diagnostic or lab reports.

What is the primary source of assessment data?

The patient.

What are secondary sources of assessment data?

Family members, other healthcare team members, and medical records.

What is subjective data?

Data from the patient's or family's point of view, including feelings, perceptions, and concerns.

How is subjective data usually collected?

Through interviews with the patient or family.

What is objective data?

Observable and measurable data collected through assessments and diagnostic tests.

What is the difference between subjective and objective data?

Subjective data are stated; objective data are observable.

What are examples of subjective data?

Patient reports pain, nausea, dizziness, or feeling tired.

What are examples of objective data?

Temperature, blood pressure, visible swelling, and lab results.

What should assessment documentation be?

Thorough, concise, and accurate.

What skills help nurses collect assessment data effectively?

Active listening, appropriate questions, assessment skills, clinical judgment, and critical thinking.

What is the analysis phase?

Identifying actual or potential patient problems using assessment data.

What is a nursing diagnosis?

A statement that identifies a patient's health problem or potential problem.

What does the RN do during analysis?

The RN interprets assessment data and uses judgment to identify patient problems.

What does an actual problem mean?

The problem currently exists.

What does a risk-for problem mean?

The problem does not currently exist but may occur because risk factors are present.

What do nurses look for when analyzing data?

Patterns, trends, and differences from expected normal values.

What is the purpose of identifying patient problems?

To guide nursing care.

What type of problem statements will we use in class?

Nursing problem statements rather than official nursing diagnoses.

What is the planning phase?

Setting priorities, identifying goals, choosing interventions, and communicating the care plan.

What does the RN do during planning?

The RN plans patient care and creates the nursing care plan.

What does the LVN do during planning?

The LVN contributes to the patient's plan of care.

What is a patient goal or outcome?

A statement describing the expected result of nursing care.

How many goals should each patient problem have?

At least one goal.

What should at least one goal directly show?

Resolution of the patient problem.

What are the four elements of a goal?

Observable, measurable, realistic, and has a timeline.

What is a short-term goal?

A goal expected within hours or days, usually less than one week.

What is a long-term goal?

A goal expected over weeks or months.

What is an example of a goal for constipation?

The patient will have a formed bowel movement daily.

What is an example of a goal for pain?

The patient will report pain at 0 on a 1–10 scale within one hour of interventions.

What is an example of a goal for impaired mobility?

The patient will ambulate with a walker in the hallway twice daily.

What is an example of a goal for low oxygen saturation?

The patient's oxygen saturation will remain above 95% with oxygen therapy by the end of the shift.

What is an example of a goal for risk for falls?

The patient will not fall during hospitalization.

What is an example of a goal for impaired skin integrity?

The patient's surgical incision will heal in 10 days.

What are nursing interventions?

Nursing actions that help achieve patient goals.

What guides the rationale for nursing interventions?

Evidence-based practice.

What are the three types of nursing interventions?

Independent, dependent, and collaborative.

What are independent nursing interventions?

Nurse-initiated actions that do not require a healthcare provider's order.

What are examples of independent interventions?

Repositioning, deep breathing, encouraging fluids, high-fiber foods, and active listening.

What are dependent nursing interventions?

Interventions initiated by a healthcare provider that require an order.

What are examples of dependent interventions?

Ordered medications, diets, urinary catheterization, and wound care.

What are collaborative nursing interventions?

Actions performed with other healthcare team members.

Who may nurses collaborate with?

Physical therapists, occupational therapists, speech therapists, social workers, and dietitians.

What should nursing interventions include?

Assessment, doing, and teaching.

Where can nurses find possible nursing interventions?

Healthcare provider orders, medical-surgical textbooks, and class notes.

What is a nursing care plan?

The plan that organizes patient problems, goals, and nursing interventions.

What is the implementation phase?

Carrying out the planned nursing interventions.

What happens during implementation?

The nurse communicates the care plan, performs or delegates interventions, supervises, continues collecting data, and documents care.

What should be documented during implementation?

The care provided and the patient's response.

What does the LVN do during implementation?

The LVN carries out nursing interventions and documents care within their scope of practice.

What is the evaluation phase?

Checking the patient's response to interventions and determining whether goals were met.

What questions should nurses ask during evaluation?

Were the goals met? Were the interventions appropriate and effective? Should goals or interventions change?

What should happen if a goal is not met?

Reassess the patient's response and consider changing the goals or interventions.

Why is evaluation important?

It shows whether nursing care is helping resolve the patient's problem.

What is Maslow's hierarchy of needs?

A theory that organizes human needs from basic survival needs to personal growth.

What are the five levels of Maslow's hierarchy, from lowest to highest?

Physiological, safety and security, love and belonging, esteem, and self-actualization.

What are physiological needs?

Basic survival needs such as breathing, food, water, sleep, and elimination.

What are safety and security needs?

Protection from danger, injury, and threats.

What are love and belonging needs?

Friendship, family, connection, and feeling accepted.

What are esteem needs?

Respect, confidence, independence, and feeling valued.

What is self-actualization?

Reaching one's potential and pursuing personal growth.

Which needs generally come first in Maslow's hierarchy?

Physiological needs, followed by safety and higher-level needs.