2 nursing process

NURSING NURSING PROCESSPROCESS

NURSING PROCESSNURSING PROCESS

LYDIA HALL (1955) Cyclic and dynamic nature Client centeredness Focus on problem-solving and

decision-making Interpersonal and collaborative style Universal applicability Use of critical thinking

NURSING PROCESSNURSING PROCESS

Copyright 2008 by Pearson Education, Inc.

Nursing Process: Nursing Process: ASSESSMENTASSESSMENT

Collecting data Organizing data Validating data Documenting data


Types of assessment: Comprehensive = complete Focused = limited to risk,

need or concern. Ongoing = follow up after

identification of specific problem


Types of data:a. Subjective Datab. Objective Data

Sources of data:a. Primaryb. Secondary


EXAMPLE:Eric’s mother states:

“ Eric vomited 8 ounces of his formula this morning”

Nursing Process: Nursing Process: DIAGNOSISDIAGNOSIS

Independent nursing function Interpretation of data for

problem identification Generate hypotheses Shows relationship of stem

and cause of the problem


Types:a. Actualb. Risk/Potentialc. Possibled. Syndromee. Wellness


Diagnostic Statements:a. One – partb. Two – partc. Three – partAvoid: Using medical diagnosis as the cause Using the s/sx as the cause

Nursing Process: Nursing Process: PLANNINGPLANNING


formulation of nursing outcomes

GOAL is exact opposite of nursing diagnosis ( stem )

S M A R T

* Priority Setting


Phases:a.Initialb.Ongoingc.Discharge


Prioritization: High priority (life-threatening) Medium priority (health-

threatening) Low priority (developmental

needs)


Standardized Plans: Standards of care Standardized care plans Protocols Policies and procedures


COMPONENTS OF A GOAL: SUBJECT: the patient

VERB: will enumerate

MODIFIER: accuratelyCRITERION 5 signs and symptoms of DM


Goal writing technique:Write goals in terms of client responses.Ex: The patient will demonstrate good

appetite.Correct: The patient will consume

95% of food served. Ex: Client will maintain good hydration.Correct: Client will drink 100cc of

water per hour


Components of nursing ordersa. Date = October 6, 2008b. Verb = Discussc. Content = to patient the

importance of…d. Time = in Saturdaye. Signature = ILI Alcazar, R.N.


Types of Nursing Orders:a. Observation orders

= auscultate lungs Q4H.b. Prevention orders

= Turn, cough and encourage DBE Q2H.

c. Treatment orders = Massage boggy fundus until firm.

d. Health promotion orders = infant stimulation techniques.

Nursing Process: Nursing Process: ImplementationImplementation

Nursing Process: Nursing Process: InterventionsInterventions

Addresses what phase of nursing process?

Types:a. Independentb. Dependentc. Collaborative

Example:Example:1. The nurse assists the client in

planning her diabetic diet in collaboration with nutritionist

2. The nurse turns the bedridden client every 1 to 2 hours

3. The nurse administers antibiotics to the client with respiratory infection

4. The nurse teaches the mother on how to burp her newborn after breastfeeding

Nursing Process: Nursing Process: InterventionsInterventions

Domains of Learning Cognitive Psychomotor Affective

Relationship of Evaluating Relationship of Evaluating to to Other PhasesOther Phases

Nursing Process: Nursing Process: EVALUATIONEVALUATION Which phase of the nursing

process are we going to evaluate?

“Changes continually”Types:a. Process Evaluationb. Structure Evaluation c. Outcome Evaluation

Nursing Process: Nursing Process: EVALUATIONEVALUATION

Example:1. Evaluates new I.V system if it resulted

to decrease incidence of phlebitis in patients with IV lines

2. Evaluates the NCP developed for patients

3. Evaluates the size and location of nursing unit in the delivery of nursing care

DOCUMENTATIONDOCUMENTATIONDocumentation: Guidelines for Documenting and

Reportinga. Client information on every pageb. Date and time each entryc. Sign each entryd. No space in betweene. Chronologicalf. Acceptable abbreviations

DOCUMENTATIONDOCUMENTATION

What to do if there is an error? Telephone order?a. Graphic record:b. Medication recordc. Progress Notes Avoid being judgmental Describe what you have observed:

DOCUMENTATIONDOCUMENTATION

Forms for data recording:A. KardexB. Flow sheet: TPR, Medication

sheet.C. Nurse’s progress notesD. Discharge summaryE. Computerized documentation

NURSING PROCESS:NURSING PROCESS:PRACTICE TESTPRACTICE TEST

A primary source for assessing how a patient slept is the:A. nurseB. patientC. physicianD. roommate

Which is an example of objective data?

A. Pain B. FeverC. NauseaD. Fatigue

Which of the following elements is best categorized as secondary subjective data?A. The nurse measures a weight loss of 10 pounds since the last clinic visit.B. Spouse states the client has lost all appetite.C. The nurse palpates edema in lower extremities.D. Client states severe pain when

walking up stairs.

An example of subjective data is that the patient:

A. appears jaundiced B. has a headacheC. looks tiredD. is crying

During the first day a nurse is caring for a client who has been in the hospital for 2 days, the nurse thinks that the client’s blood pressure (B/P) seems high. What is the next step?A. Ask the client about past blood

pressure ranges.B. Review the graphic record on the

client’s record.C. Examine the medication record for

antihypertensive medications.D. Review the progress notes included in the client’s record.

Which of the following behaviors is most representative of the nursing diagnosis phase of the nursing process?A. Identifying major problems or

needsB. Organizing data in the client’s

family historyC. Establishing short-term and long- term goalsD. Administering an antibiotic

Which of the following behaviors would indicate that the nurse was utilizing the assessment phase of the nursing process to provide nursing care?A. Proposes hypothesesB. Generates desired outcomesC. Reviews results of laboratory

testsD. Documents care

Which of the following is an incorrect statement of Nursing Diagnosis?

A.Anxiety related to insufficient knowledge regarding surgical experience

B.Constipation related to decreased activity and fluids

C.High risk for ineffective airway clearance related to pneumonia

D.Readiness for Enhanced Coping

The nurse selects the nursing diagnosis of Risk for Impaired Skin Integrity related to immobility, dry skin, and surgical incision. Which of the following represents a properly states outcome/goal? The client will:A. Turn in bed q2h.B. Report the importance of applying

lotion to skin daily.C. Have intact skin during

hospitalization.D. Use a pressure-reducing mattress.

Which of the following is an incorrect statement of outcome criteria?

A.Ambulates 30 feet with cane after discharge

B.Discusses fears and concerns regarding surgical procedures during preoperative teaching

C.Demonstrates proper coughing technique after the teaching session

D.Reestablishes normal pattern of bowel elimination

Which of the following client should be attended first by the nurse?

A.The client with cough and colds

B.The client with pain on the chest

C.The client with fever due to infection

D.The client who is for discharge

Which action would meet a patient’s basic physiologic needs?A. Raising the side rails

B. Providing a bed bath

C. Explaining proceduresD. Conversing with the patient

Which of the following is the primary purpose of the evaluating phase of the care-planning process to determine whether?A. Desired outcomes have been

met.B. Nursing activities were carried

out.C. Nursing activities were

effective.D. Client’s condition has changed.

The client has a high-priority nursing diagnosis of Risk for Impaired Skin Integrity related to the need for several weeks of imposed bed rest. The nurse evaluates the client after 1 week and finds the skin integrity is not impaired. When the care plan is reviewed, the nurse should perform which of the following?A. Delete the diagnosis since the problem has not occurred.B. Keep the diagnosis since the risk factors are still present.C. Modify the nursing diagnosis to Impaired Mobility.D. Demote the nursing diagnosis to a lower priority.

If the nurse planned to evaluate the length of time clients must wait for a nurse to respond to the client need reported over the intercom system on each shift, which of the following processes does this reflect?A. Structure evaluationB. Process evaluationC. Outcome evaluation D. Audit

After making a documentation error, which action should the nurse take?A. Use correcting liquid to cover the mistake and make a new entry.B. Draw a line through it and write

error above the entry.C. Draw a line through it and write

mistaken entry above it.D. Draw a line through the mistake

and write mistaken entry with

initials above it.

A 74-year-old female is brought to E.D. c/o right hip pain. The right leg is shorter than the left and is externally rotated. During inspection, the nurse observes what appears to be cigarette burns on the client’s inner thighs. Which of the following is the most appropriate documentation?A. Six round skin lesions partially

healed, on the inner thighs bilaterallyB. Several burned areas on both of the client’s inner thighsC. Multiple lesions on inner thighs

possibly related to elder abuseD. Several lesions on inner thighs

similar to cigarette burns

Under what circumstances is it considered acceptable practice for the nurse to document a nursing activity before it is carried out?A. When the activity is routine (e.g.,

raising the bed rails)B. When the activity occurs at regular intervals (e.g., turning the client in bed)C. When the activity is to be carried

out immediately (e.g., a stat medication)

D. It is never acceptable.