Term
| WHo first used the term nursing process? What was the first book describing the nursing process? |
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Definition
Lydia Hall in 1955 first used the term “nursing process”
1960’s nursing theorists began to describe nursing as a distinct entity among healthcare professionals and delineated steps in a process approach to nursing.
1967, first book published by Yura and Walsh that described four steps-
Assessment
Planning
Intervention
Evaluation |
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Term
| What are the five steps of the nursing process? |
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Definition
A systematic, rational, logical way of planning and providing care
ADPIE
Assess- What you see, smell, hear, touch
Diagnose: - What’s the problem?
Plan- What can you do to improve the problem today?
Implement- DO IT!!! (the plan)
Evaluate- Was it as great as you thought it was going to be?????? Did it achieve the desired outcome? If not, revise it……. |
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Term
| Describe assessment in the nursing process: |
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Definition
1. Identify priorities
2. Collect client data through observation, interview, and physical examination
3. Continuously updating the database of information
4. Analyzing data |
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Term
| What types of assessments are used? |
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Definition
Initial- Admission assessment (Comprehensive assessment must be completed by RN)
HPI, PMH, PSH, Social Hx
Focused- can be completed by an LVN
Onset, location, duration, characteristics, associated s/s, Rx, treatments
Emergency
Physical/psychological crisis
Time Lapsed- f/u in 2 weeks in clinic |
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Term
| How does a nurse establish priorities? |
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Definition
Maslow’s Hierarchy:
Physiologic
Safety
Love
Self-Esteem
Self-actualization
Review patient chart
Culture
Need for Nursing |
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Term
| What is the difference between subjective and objective data? |
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Definition
Objective
Signs an observer can see, hear, feel, smell, detect in other ways.
Objective data is measurable.
Subjective
Perceived by the patient. Signs apparent only to the patient.
If you can quote a complaint, it is subjective: “My stomach hurts” |
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Term
| Describe nursing diagnosis in the nursing process: |
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Definition
1. Identification of client's or actual potential health problems
2. Problmes can be managed by independent nursing actions
3. Guide for identifying nursing priorities and directing nursing
Three parts: example
Diagnosis: Impaired skin integrity
Related to: immobility
As evidenced by: 2 cm area of non blanhable redness |
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Term
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Definition
North American Nursing Diagnosis Association identified and developed Nursing Diagnosis. (1st appeared in the literature in 1950’s)
Purpose: to define and promote a system which refers to the diagnostic reasoning process and standardizes nursing care |
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Term
| What is the difference between a medical diagnosis and a nursing diagnosis? |
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Definition
Medical Diagnosis is made by a physician, and refers to a disease process. The disease itself doesn’t change.
Nursing Diagnosis is always changing! It is made by a nurse, and refers to how the patient responds to their illness.
TYpes of nursing diagnosis:
Actual
Risk for…
Potential
Wellness-higher level of health |
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Term
| What are some descriptive adjectives used in nursing diagnoses? |
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Definition
Deficient
Impaired
Decreased
Ineffective
Compromised |
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Term
| What are short term vs long term goals? |
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Definition
Short Term Goals (during your shift)
Long Term Goals (longer than 1 week)
All interventions and evaluations are focused on the goal/outcome achievement |
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Term
| What are characteristics of patient centered goals? |
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Definition
SMART
Specific
Measurable
Attainable
Realistic
Timed |
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Term
| How do nursing interventions differ from medical interventions? |
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Definition
MD initiated:
Needs an order
Usually addresses the medical condition
Medications, wound care, tests and treatments
Diet
Standing Orders
RN Initiated: Autonomous
Using scientific rationales, nurses can implement nursing orders that address patient responses
Do not need a physician order
Protocols |
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Term
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Definition
Utilizes all of the health care team
MD can order
RN can suggest (and should!)
Consult dietician to help
with problematic eater
Consult pharmacist
when in doubt about math! |
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Term
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Definition
Planned, ongoing, purposeful activity to evaluate:
The effectiveness of the nursing care plan.
Determine patient’s progress toward achievement of goal
Determines if nursing interventions should be terminated, continued or changed |
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Term
| How do you write the nursing diagnosis? |
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Definition
Cluster abnormal data to identify the problem
Write your nursing diagnosis using this data as support
Identify what outcome you want to achieve (goal)
Plan how to resolve or improve the identified problem (your nursing intervention) |
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Term
| What is clinical judgment? |
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Definition
| critical thinking in nursing practice |
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Term
| What is clinical reasoning |
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Definition
| process to use information, analyze data, make decisions about patient care |
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Term
| How are novice nurses hindered by their thinking process? |
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Definition
Knowledge is organized as separate facts
Focus too much on actions, forgetting to assess before acting
Need clear cut rules
Unaware of resources
Hindered by anxiety and lack of self-confidence
Rely on step-by-step procedures (focus on procedures rather than the patient’s response to the procedures)
Uncomfortable if patient needs alter the performance of activities
Question and collect data more superficially
Follow standards and policies as written
Learn best when partnered with a supportive mentor or preceptor |
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