6 Steps of the Nursing Process Flashcards

Questions and Answers

What is the first step in the nursing process?

Assessment (correct)

Outcome Identification

Evaluation

Diagnosis

What is included in the assessment step of the nursing process?

Collecting data, reviewing clinical records, health history, physical examination, functional assessment, and risk assessment.

Which of the following is NOT a part of the diagnosis step?

Test hypothesis

Document diagnoses

Compare clinical findings

Identify expected outcomes (correct)

What are the key components of outcome identification?

Identify expected outcomes, individualize to the person, ensure cultural appropriateness, realism, measurability, and include a timeline. Signup and view all the answers

What is a primary focus of the planning step in the nursing process?

Identify interventions Signup and view all the answers

Implementation involves coordinating care delivery and providing health teaching.

True Signup and view all the answers

What are the main components of the evaluation step?

Progress toward outcomes, ongoing evaluation, including patient and significant others, revising diagnoses and plans, and disseminating results. Signup and view all the answers

Study Notes

Assessment

Collect comprehensive data through various methods including clinical record reviews, health history, physical examination, and functional assessment.
Conduct risk assessments and review existing literature to inform understanding.
Employ evidence-based assessment techniques to enhance data accuracy.
Document all relevant information to maintain a clear patient record.

Diagnosis

Compare clinical findings against normal and abnormal variations and developmental events for accurate diagnosis.
Interpret collected data by identifying clusters of clues, formulating hypotheses, and validating findings.
Document confirmed diagnoses to ensure continuity of care.

Outcome Identification

Identify expected outcomes tailored to the individual patient.
Ensure outcomes are culturally appropriate and achievable within realistic parameters.
Establish measurable goals that include a specific timeline for evaluation.

Planning

Prioritize patient needs to guide the planning process effectively.
Develop clear outcomes that outline desired patient results.
Set specific timelines for achieving outcomes to facilitate monitoring.
Identify interventions based on scientific evidence and trends in research.
Document the entire plan of care to provide a structured approach to treatment.

Implementation

Execute interventions in a safe and timely manner to promote patient well-being.
Utilize evidence-based interventions to increase the effectiveness of care provided.
Collaborate with colleagues and utilize community resources to support patient care.
Coordinate care delivery to ensure comprehensive support for the patient.
Provide health education and promote health practices among patients.
Document implementation processes and any modifications made to plans.

Evaluation

Assess progress toward established outcomes to determine the effectiveness of interventions.
Conduct systematic, ongoing evaluations based on set criteria to ensure quality care.
Involve the patient and significant others in the evaluation process for a holistic perspective.
Use ongoing assessments to make necessary revisions to diagnoses, outcomes, and planning.
Share results of evaluations with patients and their families to foster understanding and engagement.

Description

Test your knowledge of the nursing process with these flashcards covering the six essential steps: assessment, diagnosis, planning, implementation, evaluation, and documentation. Each card provides definitions and key concepts to help you grasp the fundamentals of nursing practice.