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nursing process
| Question | Answer |
|---|---|
| What is the nursing process | Method for org and deliv nurs care based on prob solving principles An org syst meth of giving goal oriented humanistic care that's both effective and efficient Method used by nurses to expedite dx & tx of actual & potential health prob |
| What are the steps of Assessment | 1)Data Collection 2)Data Validation 3)Data Organization 4)Data Analysis 5)Data RecordingReporting |
| What skills do you use to NP | Knowledge Critical Thinking Nursing Skills-Techinical- Interpersonal- Behaviors Affecting Relationships-Caring |
| How do you assess | 1)Observe 2)Interview 3)Physical Assessment |
| What is the significance of Nursing Diagnosis? | Pivotal Point Probs identified are building blocks for Care plan- Identify strengths as well so patient can participate in own care |
| What are the parts of a Nursing Diagnosis | 1)problem 2)RTo factors contributing to problem |
| What is the criteria for a nursing Diagnosis | specific- measurable- realistic |
| What are the types of assesment? | Initial and Ongoing |
| What are some other names for Initial Assessment? | Baseline- Comprehensive- Data base |
| What are the 2 types of Focused or Ongoing Assessment? | Trend and Decision |
| What are you looking at in a Trend Assessment? | limited data variables short time- Changes over a an amount of time- Hours or a shift or week. |
| What are you looking at in a Decision Assessment? | specific may be only one piece of data- immediate minutes to hours- Looking for data around a specific issue |
| Historical Development of NP | 1st was 4 step- then separated out D as sep step- 1991 ANA added Outcomes as 6th step but not universally used. |
| What are advantages of NP to patient | improved quality of care by getting ND right the 1st time- so we waste less time trying to figure out how to move forward- continuity of care and on the right path- participation in his own care- pt. need centered- cost effective- systematic |
| What is purpose of Assessment? | concerned with client's overall health status & used to make an initial problem list- Big picture |
| Initial Assessment includes? | Nursing History- Physical Examination- Mulitple Data Variables- lifelong- years- months |
| Ability to identify significant cues and make correct inferences is influenced by the nurses? | 1)observational skills 2)nursing knowledge 3)clinical expertise 4)values & beliefs |
| What is the purpose of validation? | to make sure your information is factual and complete |
| What techniques do you use to validate data? | double ck equip- re ck your own data- look for factors that affect accuracy- ask a colleage to collect same data- dbl ck abnormal data- clarify pt & fam statements & verify inferences- compare impressions w/ health care team. |
| What should be end result of data validation? | Data should be accurate and complete |
| How do you organize/cluster data? | Head to toe- body systems (both med models)- Doenges/Moorhouse-Diagnostic divisions (can cluster furthe w/in divisions) |
| What are you doing in the data analysis part of assessment? | identifying patterns/testing 1st impressions |
| How do you analyze data during assesment? | decide what's relevant- make tentative decisions about meaning of data- look for gaps- do focus assesment to gather additional data needed and to determine what data is relevant/irrelevant. |
| If you analyze the data correctly what is the end result? | identify all the problems- label problems- correctly- recognize strengths- identify appropriate individualized interventions |
| If you don't analyze data correctly you will | miss problems- mislabel problems- identify problems that aren't there- identify interventions that aren't likely to help and may harm patient |
| What happens during the reporting/recording phase of assessment? | deciding what to report and deciding what to record |
| How does Assessment funnel into ND | gather data- validate data- org data- identify patterns/testing first impressions- report/record data all lead to Interpreting Data and Analysis and Synthesis which then is pinpointed into a ND |
| Critical Thinking Attitudes: | Confidence- Thinking Independently- Fairness- Responsibility and authority- Risk Taking- Discipline- Perseverance- Creativity- Curiosity- Integrity- Humility |
| Components of Critical Thinking: | Specific knowledge base in nursing- Experience- Critical Thinking Competencies (a-general b-specific CT comps in clinical situations c-specific CT comps in NP)- Attitudes of CT- Standards of CT- Profess Standards (ethic nurs judge-crit for eval-prof resp) |
| Steps of Data Analysis: | 1) Recognize a pattern or trend 2) Compare with normal standards 3) Make a reasoned conclusion |
| Examples of Indirect Care Activities: | Documentation- Delegation of care- Medical Order trnscrption- Infection control(proper hndl supplies-protect isolation)- Env safety mngmnt- Computer Data entry- tele consult with dr- collect label xfer specimens- trnsprt pt to procedure area |
| What is the nurse responsible for in regards to Collaborative problem complications? | 1) detecting and reporting any signs or symptoms of potential complications requiring physician-prescribed interventions 2)implementing Dr prescribed interventions 3) initiating interventions within the nursing domain to manage the problem |
| What does the Planning step involve? | 1) setting priorities 2) establishing outcomes/goals 3) determine nursing interventions 4) ensuring the plan is adequately recorded |
| What are questions to ask when critical thinking and setting priorities? | 1) What problems need immediate attention 2) What problems hv simple solutions 3) What probs must be referred 4) What probs must be addressed by plan of care 5)Aren't cvrd by standard plans |
| What is 1st principle theory do we use to set priorities? | Maslow's Hierchy of needs- physiological- safety- love- self esteem- self actualization |
| High priority is given to problems that are contributing factors to other problems- give example | refuses to walk b/c of pain |
| Priority ratings are influenced by: | 1)pt perception 2)the big picture 3)health as a whole 4)Length of stay 5) existence of stnd care plan- critical pathways- protocals |
| Actual probs have higher priority than potential probs with exception of: | example- Risk for Falls takes precedent over Self Care Deficit bathing/hygiene |
| T or F- A problem has to be resolved b4 another is considered | false |
| What is the purpose of client goals and outcomes? | 1) measuring sticks of the plan of care 2) direct interventions 3) motivating factors |
| What is the time frame of a short-term goal | Can be met within days or 1 wk |
| What is the time frame of a long term goal | requires longer time weeks to months |
| Discharge goals time frame | May be STG or LTG- emphasis on early identification of these goals |
| Outcome/Goal Standards | 1)derived from ND 2) doc in measurable terms 3) mutually form with client when possible 4) Realistic to client's present & potential capabilities 5) attainable in relation to resources 6) written w/ time est for attainment 7)reflect accp standrds |
| What are the criteria for goals? | specific- measurable- realistic statements |
| Goal statements must include: | Subject (who expected to achieve goal)- Verb (what do to achieve goal)- Condition (under what circumstances)- Criteria (how well is person to perform the action)- Specific Time |
| Is it appropriate to have more than one goal per ND? | yes- but at least one should demonstrate resolution improvement or control of ND |
| Goal/Outcome stmnts address which side of ND statement? | problem side- ex- risk for infection becomes will be free from infection AEB |
| Goal verbs are either | affective or cognitive or psychomotor |
| List some affective domain verbs | express share listen communicate relate |
| list some cognitive domain verbs | teach discuss identify describe list explore state explain |
| list psychomotor verbs | demonstrate practice perform walk administer give |
| affective domain goals are measurable or non measurable | non measurable and therefore not used in the hospital setting much b/c they reflect behavior/life change |
| In planning interventions what does the nurse need to understand about dependent or Physician Prescribed Interventions | What action- Why action- How- When and how often- How much- How long- What route |
| Other terms for Independent Nursing Interventions: | Nursing Actions- Nursing Measures- Nursing Orders- Nursing Strategies- Nursing Tasks- Nursing Skills |
| What are first 2 of 4 key questions must you consider when determining specific nursing interventions? | 1) What can be done to prevent or minimize the risks or causes of the problem 2) What can be done to minimize effect of problems |
| What is questions 3 out 4 you must consider when determining specific nursing interventions? | 3) How can nurse tailor interventions to meet this individual person's goals/outcomes |
| What is the 4th question a nurse must consider when determining specific nursing interventions? | 4) How likely is nurse to get desired versus adverse responses to the interventions and what can be done to reduce the risks and increase the likelihood of beneficial resp |
| List 2 of 13 guidelines for determining nursing interventions | determine baseline of current signs/symptoms- look for inter that prevent or minimize underlying causes of problem & help achieve expected outcome |
| when determining nursing interventions always: | Weigh risks & benefits- decide if you're willing to be accountable for the responses to the interventions you prescribe- Comply with agency stndrds and Dr orders |
| Nursing Interventions should include: | 1) specific action verb 2) a prescribed activity 3) specific times to be done when appropriate 4) number each one 5) specifics as who what when where how if needed for clarity |
| Interventions on care plan are listed in order of ND and the last one is always | ADPIE- Evaluate all nursing interventions effectiveness |
| Implementation is putting the plan into action How is that accomplished? | Preparing for report and getting report- Setting daily priorities- Assessing appropriateness of and readiness for interv- Perform interv & reassess- Making immed change as needed- Charting to monitor progress & communicate care |
| How do you prepare for report? | learn about pt probs- look up common tx- read charts- get to unit early- use wksht to give report |
| During Implementation setting daily priorities involves: | quick rounds to get big pic- verify crucial info immedi after shift report- id urgent probs & take action- list pt major probs in relation to ex outcomes- determ inter that must be done- decide what pt can do on own or delegate or what you do-make wksht |
Created by:
lashford
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