What is the nursing process?
An accepted standard for the practice of nursing by A.N.A . that is basically problem solving involving 7 distinct characteristics.
What are the 7 distinct characteristics of the nursing process?
1.) With the legal scope of nursing2.) Based on knowledge 3.)Planned4.) Client centered 5.) Goal Directed 6.)Prioritized 7.) Dynamic
What are the 5 steps in the nursing process?
1.) Assessment2.)Diagnosis3.)Planning4.)Implementation5.) Evaluation
Assessment
the systematic collection of facts or data. 1st step in nursing process.
ojective data
observable and measurable facts, referred to as signs of disorder, ( Ex. Blood Pressure , weight, bleeding) (Can see with eyes)
Subjective Data
information perceived only by the affected person. Aka pts. symptoms. (Ex: Pain, fatigue ) (only info they can provide)
Name some different types of Assesments
Data base assessmentFocus Base assessmentFunctional base assessment pg 22 table 2-2
Diagnosis
Identification of an injury or disease. step 2 of nursing process.
What are the 5 groups of nursing diagnosis?
actual, risk, possible, syndrome, wellness
actual diagnosis
a client problem that is present at the time of the nursing assessment
risk diagnosis
a problem the client is uniquely at risk for developing
possible diagnosis
problem that may be present, but more information is needed to rule out or confirm its existence
syndrome diagnosis
a diagnosis that is associated with a cluster of other diagnoses
wellness diagnosis
situation in which a healthy person obtains nursing assistance to maintain his or her health or perform at a higher level
Planning
determining organizational goals and a means for achieving them. must have short and long term goals. Step 3 in nursing process.
What are the 4 part of planning?
the process of prioritizing nursing diagnoses and collaborative problems, identifying measurable expected outcomes, selecting appropriate interventions, and documenting the plan of care.
Outcome criteria is sometimes called
goals
Short Term Goals
achieved in days or weeks
Long Term Goals
achieved in a few weeks to several months
Planning Measures
to accomplish identified goals involves critical thinking
Planned interventions
must be safe; with legal scope of nursing practice; and compatible with medical orders.
What are the specifics of nursing process planning documentation?
Plan of careNursing orderAgency
Plan of care
to be written by hand, standardized form, computer generated based upon agency's written standards or clinical pathways. This is a joint commission requirement .
Nursing Order
directions for a client's nursing care.Provides specific instructions so that all health team members know what to do for the patient.
Agency
specific standards for care and clinical pathways: indicate activities provided to ensure quality, consistent care.
Implementation
carrying out the plan of care. step 4 in nursing process.
Evaluation
nurse determines/ analyze whether client has reached goals. 5th step in nursing process.
Nurse Practice Act
law established to regulate nursing practice* to do less implies negligence.
When managing the care of a client, which nursing action is most appropriate to perform first?A.) Develop a plan of care.B.) Determine the client's needs.C.) Assess the client physically.D.) Collaborate on goals for care.
C. ) Assess the client physically.
According to most nurse practice acts, if a charge nurse assigns a LPN to admit a new client, what is the practical nurse's primary role?A.) Create an initial nursing care plan.B.) Gather basic information from the client.C.) Develop a list of the client's nursing diagnoses.D.) Report assessment data to the client's physician.Test-Taking Strategy: Apply the responsibilities of the practical nurse to help select the answer.
B.) Gather basic information from the client.
When staff members discuss a client's nursing diagnoses at a team meeting, which nursing diagnosis is of the highest priority?A.) Ineffective airway clearanceB.) Ineffective copingC.) Deficient diversional activityD.) Interrupted family processes
Ineffective airway clearance * ?
The LPN notes that an expected outcome of bathing independently has not been reached by the target date. What action is most appropriate to take at this time?A.) Urge the client to try harder to bathe independently.B.) Limit bathing until the client can bathe independently.C.) Suggest that the staff reduce assistance with bathing.D.) Revise the interventions or target date for achieving the goal.
D.) Revise the interventions or target date for achieving the goal.
When gathering nursing data on a newly admitted client, which is the most appropriate source to consult for additional information?A.) The client's visitorsB.) The client's familyC.) The client's clergyD.) The client's employer
B.) The client's family
self harm
#1 in safety procaution, feeling helpless, sh scars ect.
three steps to a diagnosis
diagnose (problem), related to (cause of the problem) and aed (as evidence by [signs and symptoms])