Nursing Process

Question 1

What is the Nursing Process?

Answer 1

science of nursing based on a framework

Question 2

What are the Nursing standards?

Answer 2

1. Assessment
2. Diagnosis
3. Outcome identification
4. Planning
5. Implementation
6. Evaluation
7. Quality of practice
8. Education
9. Professional practice evaluation
10. collegiality
11. collaboration
12. Ethics
13. Research
14. Resource utilization
15. Leadership

Question 3

What is the focus of the nursing process?

Answer 3

To identify potential risk, expected outcomes and provide a systematic and organized plan of care for the preoperative pt

Question 4

Characteristics of the nursing process?

Answer 4

1. Standard
2. Integrative
3. Systemic
4. Dynamic
5. Interpersonal
6. Goal and outcome oriented
7. Universal

Question 5

Standard

Answer 5

standard of practice by which all nurses are expected to perform competently

Question 6

Intergrative

Answer 6

Incorporates an holistic, caring perspective, research and evidence based perspective to integrate the science and art of nursing to meet the pt. needs

Question 7

Systemic

Answer 7

Suggest orderly sequence of activities and problem solving activities
Progresses towards identified expected outcomes
scientific and evidence based

Question 8

Dynamic

Answer 8

An integration of single action that occur at the same or similar time
flexible- can be modified to pt needs

Question 9

Interpersonal

Answer 9

Pt. centered
outcome focused
Not tasked centered

Question 10

Goal and outcome oriented

Answer 10

Matched with corresponding diagnosis and intervention
Most important to pt care establish
promotes continuity of care and provides direction on how to proceed

Question 11

Universal

Answer 11

provides working frame for all nursing activities

Question 12

Assessment

Answer 12

1. collection data
2. pt history and physical
3. medical record review

Question 13

diagnosis-purpose

Answer 13

analyze assessment data to determine pt diagnosis

Question 14

*preoperative diagnosis?

Answer 14

1. anxiety ( unfamiliar environments, impending surgery)
2. Fear ( potential outcome)
3. Grieving ( loss of body parts)
4. Risk for imbalanced fluid volume ( NPO status, preexisting condition)
5. imbalanced nutrition less than body requirement
6. Risk for aspiration ( NPO status, preexisting condition)

Question 15

*intraoperative diagnosis?

Answer 15

1. Risk for impaired skin
2. risk for peripheral neurovascualar dysfunction
3. Risk for infection ( break in aseptic technique)
4. Risk for preoperative positioning injury
5. Decreased cardiac ( anesthetic medication, decreased mobility, venous pooling)
6. Ineffective breathing mechanism (anesthetic medication)
7. Hypothermia (cool room, cool prep, exposure for surgery, open body cavity)
8. Risk for imbalance fluid ( loss of body fluid, preoperative NPO status)
9. Risk for injury ( incorrect counts, equipment malfunction, burns, improper use of ESU, pooling of prep solution, falls)

Question 16

• Postoperative diagnosis?

Answer 16

1. Impaired spontaneous ventilation (tongue blocking airway, retained secretions, surgical procedure)
2. Risk for bleeding ( blood and fluid loss)
3. Risk for deficit fluid volume ( inadequate volume)
4. Impaired gas exchange( excess and deficient in oxygenation)
5. Acute pain (surgical incision)
6. Hypothermia ( core temp < 36 C)

Question 17

Identification of outcome

Answer 17

RN identifies expected outcomes for individualized plan of care
eg. pt is free from signs and symptoms of injury related to positioning

Question 18

Planning

Answer 18

establish goals and outcomes
eg. select interventions to assess baseline skin condition, appropriate positioning aid, plan for post operative skin assessment

Question 19

Implementation

Answer 19

To carry out a plan of care
eg. assess skin condition pre and post op
pad and position patient to maintain appropriate body alignment and promote skin integrity

Question 20

Evaluation

Answer 20

Identify if expected outcomes were met

eg. evaluate for physical injury to skin and tissue

Question 21

Assessment key words on exam?

Answer 21

1. Collects
2. Identifies
3. Confirms
4. Verifies

Question 22

Diagnosis key words on exam?

Answer 22

1. Risk for
2. Statement such as Fear
3. Objective statement such as hypothermia

Question 23

Identification of outcome key words on exam?

Answer 23

Pt will be free from

Question 24

Plan of care key words on exam?

Answer 24

focus is the planning

Question 25

Implementation as key words on exam?

Answer 25

Actions or interventions to be taken by the RN 1. performs 2. provides 3. implements

Question 26

Evaluation key words on exam?

Answer 26

1. Evaluate | 2. Ensures