Week One August 31st: Didactic 1. Student. Nursing Process
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107 Terms
What is the Nursing Process?
The Nursing Process is a problem-solving loop used to provide quality nursing care. It is a systematic framework for collecting information, identifying problems, planning care, implementing interventions, and evaluating whether the plan is working.
What are the five steps of the Nursing Process?
Assessment
Diagnosis
Planning
Implementation
Evaluation
Is the Nursing Process linear?
No. It is an ongoing process. If evaluation shows that the patient's outcomes have not been met, the nurse returns to assessment and updates the plan of care.
How is the Nursing Process similar to the scientific method?
It is a systematic way of organizing practice: the nurse gathers data, analyzes the information, identifies problems, determines desired outcomes, plans care, implements interventions, and evaluates the results.
What is the relationship between the Nursing Process and the Clinical Judgement Model?
The Clinical Judgement Model is a framework used alongside the Nursing Process to help nurses develop nursing judgment and actions based on an evolving patient situation.
What is nursing?
Nursing is described as a unique blend of art and science applied within interpersonal relationships to promote wellness, prevent illness, and restore health in individuals, families, and communities.
What are the primary goals of nursing?
Determine client/family responses to human problems, level of wellness, and need for assistance.
Provide physical care, emotional care, teaching, guidance, and counseling.
Implement interventions aimed at prevention and helping clients meet their own needs and health-related goals.
Is nursing simply the application of skills?
No. Nursing involves more than applied skills and individual care. It includes promoting and maintaining health, addressing mental and physical health, and considering the patient's relationships, developmental stage, health/illness continuum, and community.
Assessment
The first step of the Nursing Process involving the collection of information/data about the patient's current health status.
What is the purpose of the assessment phase?
To gather information about the patient's psychological, physiological, sociological, and spiritual status.
What types of information are collected during assessment?
Both subjective and objective data are collected. Assessment may include interviewing the patient, performing a physical assessment, taking vital signs, reviewing health and family histories, observing the patient, and noting diagnostic laboratory results.
What does the term "patient's story" mean?
It refers to a holistic assessment of information about the client, including input from the client and family whenever possible.
What are some methods nurses use to collect assessment data
Patient interview
Physical examination
Health history
Family history
General observation
Vital signs
Diagnostic laboratory results
Why are communication techniques important during assessment?
Communication techniques are important throughout the entire Nursing Process and are particularly important during assessment because the nurse needs to obtain the patient's story and gather accurate information.
Subjective Data
Information representing the patient's perceptions, feelings, concerns, symptoms, or statements. It is generally not directly measurable.
Objective Data
Information obtained through direct RN observation and information that can be measured through physical examination, observation, or testing
What is the primary source of subjective data?
The patient is the primary source because subjective data consists of the patient's statements, perceptions, feelings, and concerns.
Can subjective data come from someone other than the patient?
Yes. Subjective data can come from either a primary source, such as the patient, or a secondary source, such as a family member or friend
What makes data objective?
It comes from direct observation or can be measured through physical examination, observation, or testing. Examples include vital signs and laboratory values.
Nursing Diagnosis
A nurse's educated judgment about an actual or potential health problem experienced by the patient.
What happens during the diagnosis phase?
The nurse clusters and analyzes assessment information and formulates an evaluative judgment about the patient's health status.
What questions does the diagnosis phase address?
What is the patient's present health status?
What is contributing to it?
What is the problem?
Is the problem actual or potential?
What is clinical reasoning?
The thinking process involved in analyzing assessment information, recognizing cues, organizing or clustering information, and determining the patient's strengths and unmet needs before making an appropriate diagnosis.
Can a patient have more than one nursing diagnosis?
Yes. A single patient may have multiple nursing diagnoses, including actual problems and risks for developing additional problems.
What is NANDA?
NANDA International is a professional organization that manages an official list of nursing diagnoses and provides a taxonomy for grouping health problems.
How does nursing language differ from medical diagnostic language?
Nursing language focuses on symptoms and the patient's experience, whereas medical diagnoses focus on the disease process.
Planning
The Nursing Process phase in which the nurse and patient establish priorities, determine desired outcomes, and select appropriate nursing interventions.
What are the two major questions asked during planning?
What is the desired patient health status?
How can nursing care help achieve the desired outcomes?
Why is mutual agreement important during planning?
The patient and nurse should agree on the diagnoses and priorities. Planning is not simply about the nurse creating a plan independently; it involves the patient and focuses on mutually agreed-upon care.
How should multiple nursing diagnoses be prioritized?
Priority should be given to severe symptoms and high-risk factors.
SMART
A framework used to create clear, measurable goals/outcomes.
What does SMART stand for?
S — Specific
M — Measurable
A — Attainable
R — Realistic
T — Timed
Why are SMART goals used in nursing care planning?
Each identified problem should have a clear, measurable goal or goals describing the expected beneficial patient outcome.
NOC — Nursing Outcome Classification
A set of standardized terms and measurements used to track patient wellness/outcomes.
What is NIC?
Nursing Interventions Classification (NIC) is a resource used when planning nursing interventions. Interventions serve as "road maps" for providing nursing care.
Implementation
The phase in which the nurse puts the plan of care into action.
What are three major activities involved in implementation?
Doing
Delegating
Documenting care/actions and the patient's response.
What happens during implementation?
The nurse carries out the specific, individualized interventions agreed upon in the plan of care. Actions are usually performed collaboratively with the patient/family and other healthcare disciplines.
What happens during implementation?
The nurse carries out the specific, individualized interventions agreed upon in the plan of care. Actions are usually performed collaboratively with the patient/family and other healthcare disciplines.
What types of actions may nurses perform during implementation?
Monitor and assess for changes or improvement
Provide direct patient care
Perform necessary skills
Educate and instruct the patient
Help with further health management
Refer or contact the patient for follow-up
How long can implementation take?
Implementation may occur over hours, days, weeks, or even months, depending on the patient's situation.
Evaluation
The Nursing Process phase in which the nurse determines whether the patient's goals/outcomes were achieved and whether the plan of care is working.
What questions are asked during evaluation?
Were the outcomes achieved?
What worked?
What did not work?
What are the possible patient outcomes
The patient's condition may be:
Improved
Stabilized
Deteriorated, died, or been discharged
What happens if the patient's outcomes are not met?
The Nursing Process begins again with assessment, and the plan of care is updated.
Medical Terminology
A system of words largely based on Latin roots that can help nurses understand medical terms rather than simply memorizing them.
What does gastroenteritis mean?
Inflammation of the stomach and intestines.
What does gastr/o mean?
Stomach
What does enter/o mean?
Intestines, usually small intestine
What does -itis mean?
inflammation
H&P
History & Physical
HPI
History of Present Illness
PMH
Past Medical History
PSH
Past Surgical History
H/O
History Of
NKDA
No Known Drug Allergies
PCP
Primary Care Physician
A&O
Alert and Oriented
Sx
Symptoms OR Surgery
Dx
Diagnosis
Tx
Treatment
NAD
No Acute Distress
C/O
Complaint Of
CC
Chief Complaint
ROS
Review of Systems
RF
Risk Factors
WDL
Within Defined Limits
WDL — Within Defined Limits
A term used when findings are within the expected limits for the situation being assessed.
D
Daily
QID
4x/day
AM
In the Morning
BID
2x/day
TID
3x/day
ac
Before Meals
pc
After Meals
HS
At Night
ā
Before
p̄
After
Q
Every
H
Hour
PRN
As needed
CTA
Clear to Auscultation
RRR
Regular Rate + Rhythm
What factors may influence a patient's normal pulse rate?
Age
Sex/gender
Exercise
Stress
Fever
Hemorrhage
Medications
Position changes
What does BPM mean?
Beats per minute
What adult respiratory rate is identify as WDL?
12–20 breaths per minute
What adult pulse rate identify as WDL?
60–100 beats per minute (BPM)
Why do we not use the word normal
Because what is considered expected depends on the patient's age and condition. The presentation emphasizes considering whether findings are expected for that particular patient rather than automatically labeling them "normal" or "good."
Fx
Fracture
Rx
Prescription
AMS
Altered Mental Status
HLD
Hyperlipidemia
HTN
Hypertension
T2DM
Type 2 Diabetes
T1DM
Type 1 Diabetes
ACS
Acute Coronary Syndrome
CKD
Chronic Kidney Disease
ARF
Acute Renal Failure
KS
Kidney Stones
CHF
Congestive Heart Failure