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Questions and Answers
What is the key characteristic of a plan of care according to the text?
What type of nursing intervention does not require an order from a healthcare provider?
What action involves transferring essential information from one nurse to the next during a transition of care?
Which phase of the nursing process involves evaluating the patient's response to interventions?
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What type of care involves treatments performed through interactions with patients directly?
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What aspect of a plan of care ensures that the goals are attainable according to the text?
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What is the first phase of the Nursing Process?
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Which step in the Nursing Process involves analyzing the collected data to identify a patient's health problem?
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What type of nursing diagnosis identifies existing health problems that require nursing interventions?
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Which type of data in Assessment includes verbal descriptions provided by the patient?
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What does NANDA stand for in the context of the Nursing Process?
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Which part of the Nursing Process involves gathering information from sources like patients, family members, and healthcare team?
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Study Notes
Nursing Process
- Nursing Process is a systematic and dynamic method used to provide individualized care to patients.
Phases of Nursing Process
- Consists of five distinct phases: Assessment, Diagnosis, Planning, Implementation, and Evaluation (ADPIE).
Assessment
- First step of the nursing process that collects data.
- Data collection methods: interview, physical examination, review of medical records, and lab reports.
- Goal is to gather relevant information from sources: patient, family members, healthcare team, and medical records.
- Cues: data obtained through senses (e.g. patient coughing and wheezing).
- Inference: interpretation of the cues (e.g. difficulty breathing).
- Data types: subjective (verbal descriptions) and objective (observations or measurements).
Diagnosis
- Analyzes the collected data to identify patient's actual or potential health problem.
- NANDA diagnosis is not a medical diagnosis, but an actual nursing diagnosis that identifies existing health problems or conditions.
- Three types of nursing diagnosis: actual, risk, and wellness.
Planning
- Involves setting goals to address the problem once diagnosis is identified.
- Collaborates with patient and healthcare team to develop plan of care.
- Plan of care should be specific, measurable, achievable, realistic, and time-bound (SMART).
Implementation
- Puts the plan of care into action by implementing interventions and strategies.
- Types of nursing interventions: independent, dependent, and collaborative.
- Examples of implementation: providing direct patient care, administering medications, performing treatments, teaching patients and families, and coordinating care with other healthcare providers.
- Handoff reporting: transferring essential information from one nurse to the next during transition of care.
- Direct care: treatments performed through interactions with patients.
- Indirect care: performed away from a patient (e.g. safety and infection control).
Evaluation
- Evaluates the patient's response to interventions and the effectiveness of the plan of care.
- Determines whether goals have been achieved.
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Description
Learn about the Assessment phase of the Nursing Process, which involves collecting data through interviews, physical examinations, and reviewing medical records. Understand the importance of gathering relevant information from patients, family members, and the healthcare team.
