What is the nursing process?
It’s a way of thinking that implements planning and giving care while applying knowledge, skills and caring into the framework.
List the components of ADPIE.
- Assessment
1) Subject data
2) Objective data - Diagnosis
1) Data analysis
2) Problem identification
3) Nursing diagnosis (NANDA) - Planning
1) Priorities
2) Nursing care plan: outcomes and interventions - Implementation
1) Nurse-initiated
2) Physician-initiated
3) Collaborative - Evaluation
1) Outcomes met?
2) If not, re-evaluate: data, diagnosis, etiologies, outcomes and interventions
How do nursing theories describe nursing? (5)
- An art & science w/ its own scientific body of knowledge
- Holistic
- Care
- Variety of settings
- Concerned w/ health promotion, disease prevention & care during illness
What is the difference b/w the nursing and medical focus?
- Medical focus:
1) Diagnose & treat illness
2) Care
3) Pathophysiological, biological & physical
4) Teach about treatments - Nursing focus:
1) Diagnose, treat & address human response
2) Care
3) Holistic + psychosocial, cultural, spiritual
4) Teach self-care + wellness activities
Define human response. Provide the 4 components.
It’s reactions to events/stressors such as disease, injury or life changes
1) Biological
2) Psychological
3) Social
4) Spiritual
State 3 reasons why the nursing process is important.
1) Unique to the pt
2) It’s a continuous process (cycle)
3) To provide effective pt care
What is the first phase of the nursing process? How is it used?
Assessment: the systemic gathering of relevant & important data on the pt’s present health status.
The data collected is used to: identify health problems, plan nursing care, and evaluate pt outcomes
How is data collected in the assessment phase?
- Interview
- Observation
- Physical exam
- Collateral info (pt chart, nurse or HCPs)
When should you organize and record data in the assessment stage?
- Initial assessment
- Ongoing assessment
- Special purpose assessments
What do critical thinkers do during the assessment stage?
- Ensure that assessment info is complete, accurate & factual before making a diagnosis
- Eliminate their own biases & misconceptions of the data
- Avoid jumping to faulty conclusions about the data
How can you validate data?
- Ask pt qs
- Compare subjective & objective data
- Compare w/ previous data
- Recheck measurements
- Ask for verification
- Use references to explain findings
What is the second phase of the nursing process?
Diagnosis: A “nursing” diagnosis identifies and labels human responses to actual and potential health problems
What must you ask yourself during the diagnosis stage? (2)
- What is the pt’s presenting health status?
- What is contributing to it?
What must you do during the diagnosis stage?
Sort, cluster & analyze data in order to identify the patient’s present health status (actual & potential health problems & strengths)
What are the three parts of a nursing diagnosis statement?
Problem (P): brief statement of the patient’s potential or actual health problem
Etiology (E): a brief description of probable cause, contributing or related factors (very important for selecting the correct interventions)
Signs & symptoms (S): a list of the cluster of the objective & subjective data that lead the nurse to pinpoint the problem
Provide 2 examples of a nursing diagnosis statement for an actual problem (3-part nursing diagnosis).
Problem + etiology + signs & symptoms:
Decreased body image related to post-surgery incision as evidenced by patient verbalization, “I look awful.”
Limited ROM unilaterally in the right arm related to swelling and surgical incision as evidenced on assessment and by the patient’s report.
Provide an example of a nursing diagnosis statement of a potential problem (2-part nursing diagnosis).
Problem + etiology:
Risk for infection related to invasive surgery.
What is the third stage of the nursing diagnosis?
Planning outcomes: after prioritizing your diagnosis, goals need to be identified.
Planning interventions: Identify independent (e.g. patient education) and dependent nursing interventions (e.g. can’t be performed by the nurse alone, such as an MD order) to accomplish the desired patient outcomes.
True or false: Goals (expected outcomes) should be pt-centered and mutually set if feasible
True
Is it important to identify both short and long term goals?
a) short-term is the most important
b) long-term will help the most
c) neither, just do what you think is right
d) both are equally important
d)
What are the components of SMART goals?
Specific Measurable Attainable Realistic Timely
Provide an example of a short-term goal. How will the effectivity be measured?
The pt will know postop expectation 1 hr after speaking w/ RN about surgery.
Pt can repeat the expectations to measure the goal’s accomplishment.
Provide an example of a long-term goal.
Pt will have a plan for discharge (pain management, homecare plan for son) in place by postop day 3
What is the fourth stage of the nursing process?
Implementation: it involves the doing, delegating and documenting.
