The Nursing Process - (Basics in Nursing) Flashcards

Terms Definitions
(def)

a systematic rational method of planning and providing nursing care
Nursing Process
(def)

the process of collecting, organizing, validating, and recording data (information) about a client's health status
Assessing
(def)

information (data) that is detectable by an observer or can be tested against and accepted standard; can be seen, heard, felt, or smelled
objective data
(def)

data that are apparent only to the person affected; can be described or verified by only that person
subjective data
(def)

the nurse's clinical judgment about individual, family, or community responses to actual or potential health problems/life process to provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
Nursing diagnosis
What are the 5 phases of the nursing process?
- assessing
- diagnosing
- planning
- implementing
- evaluating
an ongoing process that involves (a) assessing a situation (b) establishing goals and objectives based on assessment of a situation or future trends (c) developing a plan of action that identifies priorities, delegates who is responsible, determines deadl
Planning
(def)

the phase of the nursing process in which the nursing care plan is put into action
Implementing
(def)

a planned, ongoing, purposeful activity in which clients and health care professionals compare expected outcomes to actual outcomes
Evaluating
(def)

the determination that the diagnosis accurately reflects the problem of the client, that the methods used for data gathering were appropriate, and that the conclusion or diagnosis is justified by the data
Validation
You observe that a patient's arm is red and tender at the IV site, and determine that it is infected and the IV will need to be relocated. What phase(s) of the nursing process were used in this case?
assessing, diagnosing, and planning
(def)

a visual tool in which ideas or data are enclosed in circles or boxes of some shape and relationships between these are indicated by connecting lines or arrows
Concept map
(def)

a collegial working relationship with another health care provider in the provision of client care
Collaboration
Nurses frequently use what reference point when setting nursing diagnosis' priorities?
Maslow's hierarchy of needs
The nursing process is required by _______ ________ __________.
National Practice Standards
In 1859, who started the movement where a nurse was said to be in charge of someone's personal health?
Florance Nightingale
In 1955, who was first to use the name "nursing process"?
Hall
In 1961, who began assisting the individual whether they were sick or well?
Henderson
In 1967, who authored the text call "The Nursing Process"? How many steps were in the process at that time?
Yura & Walsh (4 steps at that time)
In 1974, who included an additional step in the nursing process, making it the 5 step process that we use today?
Gabbie & Lavin
What organization publishes a list of nursing diagnoses? How often is it published?
NANDA - every 2 years
What are 7 characteristics of the nursing process?
- individualized
- systematic
- dynamic
- interpersonal
- outcome oriented
- universally applicable
- problem-solving approach
What are 3 types of data collected in the assessment phase of the nursing process?
- objective
- subjective
- historical
A client tells you that they feel nauseated. What type of data is this?
subjective data (aka symptoms)
You do a physical assessment on a client. What type of data is this?
objective data (aka signs)
A client tells you that they are allergic to penicillin. What type of data is this?
historical data
What is the primary source of data? What is an example of secondary source of data?
The client is the primary source of data. A family member or neighbor would be a secondary source of data.
Which phase of the nursing process?

Obtain a nursing health history
Assessing
Which phase of the nursing process?

Conduct a physical assessment
Assessing
Which phase of the nursing process?

Review Client records and review nursing literature
Assessing
Which phase of the nursing process?

Consult support persons and health professionals
Assessing
Which phase of the nursing process?

Update, organize, and validate data
Assessing
Which phase of the nursing process?

Compare data against standards
Diagnosing
Which phase of the nursing process?

Cluster or group data
Diagnosing
Which phase of the nursing process?

Identify gaps and inconsistencies
Diagnosing
Which phase of the nursing process?

Determine client's strengths, risks, diagnosis, and problems
Diagnosing
Which phase of the nursing process?

Set priorities and goals/outcomes in collaboration with client
Planning
Which phase of the nursing process?

Write goals/desired outcomes
Planning
Which phase of the nursing process?

Select and write nursing interventions and nursing care plan
Planning
Which phase of the nursing process?

Communicate care plan to relevant health care providers
Planning
Which phase of the nursing process?

Perform planned nursing interventions.
Implementing
Which phase of the nursing process?

Document care and client responses to care
Implementing
Which phase of the nursing process?

Give verbal reports as necessary
Implementing
Which phase of the nursing process?

Judge whether goals/outcomes have been achieved and modify or terminate care plan
Evaluating
Which phase of the nursing process?

Make decisions about problem status
Evaluating
Which phase of the nursing process?

Cluster data to categorize behaviors which reveals the problem
Diagnosing
During diagnosing, the ________ becomes the nursing diagnosis.
problem
Analyzing and synthesizing data occurs during the ________ phase.
Diagnosing
When planning you should write a ______ for each problem and an expected ________ for each defining characteristic.
goal

outcome
Should the goal be broad or specific? What about the outcome?
The goal should be broad, and the expected outcome should be specific.
(def)

broad statement reflecting resolution of the problem
Goal
(def)

specific, measurable statements that reflect resolution of the defining characteristics
Expected Outcomes
Is the following a goal or outcome?

"Ms. Reynolds' anxiety will decrease within 1 week AEB"
Goal
Is the following a goal or outcome?

"respiration rate between 12-20 per minute, with no SOB"
Outcome
Signs and symptoms are referred to as what?
Defining characteristics
What is the focus of a medical diagnosis?
the illness
What are the 2 primary purposes of writing goals/outcomes?
- serves as criteria for evaluation of client progress
- provides direction for nursing interventions
(def)

actions that the nurse takes to prevent, reduce or eliminate the problem or diagnostic label
Nursing interventions
Should a nursing intervention be general or specific?
specific, it should tell who, what, when, where, and how often
What are the 3 types of nursing interventions?
- physician-initiated
- nurse-initiated
- collaborative
What is a dependent order?
a physician-initiated order
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