Nursing Process Part 2

Question 1

Assessment:

What are the 5 types of nursing assessments?

Answer 1

comprehensive initital
focused 
emergency 
time-lapsed 
patient centered assessment method

Question 2

What are some skills that help with critical thinking?

Answer 2

reflective practice: journaling and debriefing

concept maps

Question 3

Explain the 5 core values of assessment:

Answer 3

• systematic and comprehensive to identify medical concerns
• determine credibility of info sources
• find normal from abnormal and risk for abnormal
• judgments of significance of data
• check accuracy, reliability, and missing info

Question 4

Assessment:

What are the 2 types of data used?

Answer 4

subjective: info perceived only by the patient
objective: observable and measurable

Question 5

Assessment:

What are some sources of data?

Answer 5

patient
family
record
medical history, physical
labs
therapies

Question 6

Assessment:

What are some problems related to data collection?

Answer 6

poor organization
failure to chart
irrelevant data
recording interpretation rather than observed data

Question 7

What are the 5 steps of assessment?

Answer 7

collect data
identify cues and make inferences
validating data 
clustering related data 
reporting and recording data 
this leads to: 
-clinical reasoning (analyzing, synthesizing, reflecting, drawing conclusions)

Question 8

What are the 5 steps of Diagnosis?

Answer 8

• creating a list of suspected problems
• ruling out similar problems
• naming actual/potential problems
• determining risk factors
• identifying resources, strengths, and areas for health promotion

Question 9

What is the prupose, vision, and mission of NANDA?

Answer 9

purpose: implementation of ND
vision: ensure patient safety through standardized terminology
mission: standardized nursing diagnostic
terminology.

Question 10

What is the difference between a ND and a medical diagnosis?

Answer 10

ND: nurse treats independently
Medical: physician directs the treatment
Collaborative: physician and nurse prescribed

Question 11

What does a ND provide?

Answer 11

• a definition of problems and common language for patient needs
• nurse communication
• focus on scope of practice
• foster nursing knowledge

Question 12

What are the 3 types of ND’s?

Answer 12

• actual: human response to health conditions or life processes
• risk: same as actual but they may develop
• health promotion: clinical judgment of motivation, desire, and readiness to enhance well-being and does not require a current level of wellness

Question 13

What are the 3 parts of the nursing diagnosis?

Answer 13

-Problem: diagnostic labe
-Etiology: related to “r/t” (don’t use medical diagnosis)
(risk and health promotion diagnosis will not have this section)
-Defining characteristics: as evidenced by AEB, (use subjective and objective data)

Question 14

How can you prioritize the ND?

Answer 14

• high: emergent
• intermediate
• low: affect future well being
• Use Maslow Hierarchy: physiologic (food, water air), safety, love and belonging, esteem, self-actualization