Nursing Interventions and Implementation Process Quiz

Nursing Process

• Nursing process is a treatment based on clinical judgment and knowledge that a nurse performs to enhance patient outcomes
• It involves five phases: assessment, diagnosis, planning, implementation, and evaluation

Assessment

• Involves collecting data about the client's health status through various methods such as inspection, palpation, percussion, and auscultation
• Types of assessment: initial, ongoing, and terminal
• Vital signs to be assessed: temperature (36.5-37.2°C), pulse rate (60-100 bpm), and respiration rate (16-20 breaths/min)
• Factors affecting vital signs: activity, talking, chewing gum, and anxiety

Diagnosis

• A clinical judgment about a client's health problem
• Example: asthma, cerebrovascular accident, amputation, appendicitis

Planning

• Deliberative and systematic phase involving decision-making and problem-solving
• Involves setting goals and outcomes, and designing a nursing care plan (NCP)
• NCP is the blueprint of the nursing process, involving individualized care for the client

Implementation

• The "doing" phase, involving direct and indirect care interventions
• Direct care: treatments performed through interaction with the patient, e.g., medication administration, vital sign checking
• Indirect care: treatments performed away from the patient, e.g., safety and infection control, delegating nurse care
• Types of interventions: dependent, collaborative, and interdependent

Evaluation

• The final step of the nursing process, assessing the client's response to nursing care and the effectiveness of the NCP
• Types of evaluation: ongoing, initial, and terminal
• Crucial to determine if the patient's condition has improved or worsened after application of the first four steps of the nursing process