The Nursing Process

Question 1

adpie

Answer 1

• assessment
• diagnosis
• planning
• implementation
• evaluation

Question 2

assessment data collection

Answer 2

• tests to see results
• objective: vitals, diagnostic test results, facts, numbers
• subjective: pain, what client is telling you, their feelings, what family sees

Question 3

assessment sources of data

Answer 3

• primary: client
• secondary: family, care taker, their chart
• tertiary: journal articles, nurses past experiences
• primary and secondary are directly related to client and tertiary is more general data

Question 4

nursing diagnosis vs medical diagnosis

Answer 4

nursing: persons response to a condition, clinical judgement, wellness promotion or potential risks, may change, shows our autonomy
- medical: the condition and causes, remains same

Question 5

steps in nursing diagnosis

Answer 5

1) identification
2) identify related factors
3) provide evidence to support diagnosis

Question 6

identification

Answer 6

• identify focus that nursing diagnosis will address by looking at patterns in data that has been collected
• focus on experience of client and this around them
• likely to have more than one diagnosis
• verify diagnosis with client

Question 7

identify related factors

Answer 7

• figure out why the client is having specific problem

- medical diagnosis can be of assistance

Question 8

provide evidence to support diagnosis

Answer 8

• summarize data in AEB statement

- justifying why they have diagnosis

Question 9

3 types of nursing diagnosis

Answer 9

• actual
• wellness or health promotion
• risk
  focusing on entire person not just diagnosis

Question 10

actual

Answer 10

• as issue for the client at the moment

Question 11

wellness or health promotion

Answer 11

readiness for enhanced education

Question 12

risk

Answer 12

things they are at risk for due to symptoms

Question 13

why is standardized nursing language important

Answer 13

• improved communication among nurses and other professionals
• increase visibility of nursing interventions
• improved patient care

Question 14

North American Nursing Diagnosis Association

Answer 14

• NANDA
• creates language to identify clients or communities responses to situations
• works closely with NIC and NOC

Question 15

Nursing intervention Classification

Answer 15

• NIC

- what we are going to do

Question 16

Nursing Outcome Classification

Answer 16

• NOC

- what we hope to see

Question 17

International Classification for Nursing Practice

Answer 17

• ICNP
• nursing diagnosis classification system supported by WHO
• language similar to NANDA
• more used for electronic records and documentation
• linked with committee for international nursing language
• includes outcome statements

Question 18

planning

Answer 18

• goals: resolution of the area of concern or achievement of the goal
• both short and long term (immediate vs future)
• outcomes: specific, measurable and patient specific. how goal will be measured, what we will see in client

Question 19

Goals should be…

Answer 19

• specific
• measurable or meaningful
• attainable or action-oriented
• realistic of results-oriented
• timely or time-oriented
• start with “increase, decrease, improve, maintain, or stabilize”

Question 20

implementation

Answer 20

• interventions: what we as nurses can to do address the areas of concern or to support wellness

Question 21

evaluation

Answer 21

• reassess or evaluate to see if desired outcomes have been met

Question 22

goals vs objectives

Answer 22

• both measurable
• goals: broad
• outcomes: measurable piece of a goal
• ex: goal- decreased work of breathing
  objective- respiratory rate between 16 and 20