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Questions and Answers
Which of the following factors should be considered when setting desired outcomes for a client? (Select all that apply)
Which of the following factors should be considered when setting desired outcomes for a client? (Select all that apply)
Goals must be derived from more than one nursing diagnosis.
Goals must be derived from more than one nursing diagnosis.
False
What is an example of an independent nursing intervention?
What is an example of an independent nursing intervention?
Physical care, ongoing assessment, emotional support, health teaching.
The type of intervention that requires orders from a licensed physician is called a ______ intervention.
The type of intervention that requires orders from a licensed physician is called a ______ intervention.
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Match the types of nursing interventions with their descriptions:
Match the types of nursing interventions with their descriptions:
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Which of the following is NOT a component of evaluation in the nursing process?
Which of the following is NOT a component of evaluation in the nursing process?
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What is the first step in the process of implementing nursing interventions?
What is the first step in the process of implementing nursing interventions?
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What is the nursing process?
What is the nursing process?
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Who originated the term nursing process?
Who originated the term nursing process?
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The nursing process consists of strictly separated phases.
The nursing process consists of strictly separated phases.
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The purposes of the nursing process include identifying a client’s health status and ________ health care problems or needs.
The purposes of the nursing process include identifying a client’s health status and ________ health care problems or needs.
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What are the five phases of the nursing process?
What are the five phases of the nursing process?
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Match the types of assessment with their purpose.
Match the types of assessment with their purpose.
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What are subjective data?
What are subjective data?
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Objective data can only be obtained through the client's verbal reports.
Objective data can only be obtained through the client's verbal reports.
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________ data are detectable by an observer or can be measured.
________ data are detectable by an observer or can be measured.
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What is the purpose of validating data in the nursing process?
What is the purpose of validating data in the nursing process?
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Which of the following are components of a NANDA nursing diagnosis?
Which of the following are components of a NANDA nursing diagnosis?
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Nursing diagnoses are the same as medical diagnoses.
Nursing diagnoses are the same as medical diagnoses.
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What is the difference between actual and risk nursing diagnoses?
What is the difference between actual and risk nursing diagnoses?
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The nursing process includes ________, Diagnosis, Planning, Implementation, and Evaluation.
The nursing process includes ________, Diagnosis, Planning, Implementation, and Evaluation.
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Study Notes
Nursing Process
- A systematic, rational method of planning and providing individualized nursing care
- Purposes:
- Identify client's health status and actual or potential health care problems or needs
- Establish plans to meet the identified needs
- Deliver specific nursing interventions to meet those needs
- Client may be an individual, family, community, or group
Phases of Nursing Process
- Assessment: collection, organization, validation, and documentation of data
- Diagnosing: interpreting assessment data and identifying client strengths and problems
- Planning: developing a plan of care to address client problems
- Implementing: carrying out the plan of care
- Evaluating: determining the effectiveness of the plan of care
- Phases are cyclical, overlapping, and interrelated
Assessment
- Systematic and continuous collection, organization, validation, and documentation of data
- Types of assessments:
- Initial assessment
- Problem-focused assessment
- Emergency assessment
- Time-lapsed reassessment
- Data collection:
- Subjective data (symptoms, perceived by the client)
- Objective data (signs, observable by others)
- Constant data (does not change over time)
- Variable data (changes over time)
- Sources of data:
- Primary sources (client, client's records)
- Secondary sources (support people, healthcare professionals, literature)
- Data collection methods:
- Observing
- Interviewing (directive and nondirective approaches)
- Examining (physical examination)
- Organizing data:
- Using a written or electronic format that organizes the assessment data systematically
- Conceptual models/frameworks (e.g., Gordon's Functional Health Patterns)
- Wellness models
- Non-nursing models
- Validating data:
- Verifying data to confirm accuracy and factualness
- Ensuring completeness and accuracy of assessment information
- Avoiding jumping to conclusions and focusing on the wrong direction to identify problems
- Documenting data:
- Recording client data in a factual manner
- Avoiding interpretation by the nurse
- Using quotation marks for subjective data
Diagnosing
- Interpreting assessment data and identifying client strengths and problems
- NANDA International:
- Defines, refines, and promotes taxonomy of nursing diagnostic terminology
- Provides standardized names for nursing diagnoses (diagnostic labels)
- Nursing diagnosis:
- A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response
- Actual, health promotion, risk, and syndrome diagnoses
- Components of a NANDA nursing diagnosis:
- Problem (diagnostic label) and definition
- Etiology (related factors and risk factors)
Note: The above notes focus on the key concepts, definitions, and details related to the nursing process, assessment, and diagnosing phases.### The Importance of Differentiating Among Possible Causes in Nursing Diagnosis
- Differentiating among possible causes in nursing diagnosis is essential because each may require different nursing interventions.
- Example: Bed rest or immobility may lead to generalized weakness, requiring different interventions.
Defining Characteristics of Nursing Diagnosis
- Defining characteristics are the cluster of signs and symptoms that indicate the presence of a particular diagnostic label.
- For actual diagnoses, defining characteristics are the client's signs and symptoms.
- For risk nursing diagnoses, there are no subjective and objective signs present.
- Example: Verbal report of fatigue or weakness.
Nursing Diagnosis vs. Medical Diagnosis
- Nursing diagnosis:
- A statement of nursing judgment that refers to a condition that nurses are licensed to treat.
- Describes the human response, a client's physical, sociocultural, psychological, and spiritual responses to an illness or health problem.
- Medical diagnosis:
- Made by a physician and refers to a condition that only a physician can treat.
- Refers to disease processes—specific pathophysiologic responses that are fairly uniform from one client to another.
The Diagnostic Process
- Analyzing data:
- Comparing data with standards (identify significant cues).
- Clustering cues (generate tentative hypothesis).
- Identifying gaps and inconsistencies.
- Identifying health problems, risks, and strengths:
- After data analysis, nurse and client identify strengths and problems.
- Determine problems that support tentative actual, risk, and possible diagnoses.
- Determine whether the client's problem is a nursing diagnosis, medical diagnosis, or collaborative problem.
Formulating Diagnostic Statements
- Most nursing diagnoses are written as two-part or three-part statements.
- Basic two-part statements:
- Problem (P): statement of the client's response (NANDA label).
- Etiology (E): factors contributing to or probable causes of the responses.
- Basic three-part statements (PES format):
- Problem (P): statement of the client's response (NANDA label).
- Etiology (E): factors contributing to or probable causes of the responses.
- Signs and symptoms (S): defining characteristics manifested by the client.
- One-part statements:
- Used for health promotion diagnoses and syndrome nursing diagnoses, consisting of a NANDA label only.
Planning
- Planning involves decision making and problem solving.
- Nursing interventions: any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient or client outcomes.
- The end product of the planning phase is the client care plan.
- Planning is a deliberative, systematic phase that involves:
- Setting priorities.
- Establishing client goals/desired outcomes.
- Selecting nursing interventions and activities.
Characteristics of a Plan
- Specific.
- Measurable.
- Attainable.
- Realistic.
- Time-bound.
Developing a Nursing Care Plan
- Formal or informal plan of care.
- Informal nursing care plan: a strategy for action that exists in the nurse's mind.
- Formal nursing care plan: a written or computerized guide that organizes information about the client's care.
- Standardized care plan: a formal plan that specifies the nursing care for groups of clients with common needs.
- Individualized care plan: tailored to meet the unique needs of a specific client.
Guidelines for Writing Nursing Care Plans
- Date and sign the plan.
- Use category headings.
- Use standardized symbols and keywords.
- Be specific.
- Refer to procedure books or other sources of information.
- Tailor the plan to the unique characteristics of the client.
- Ensure that the nursing plan incorporates preventive and health maintenance aspects.
- Ensure that the plan contains ongoing assessment of the client.
- Include collaborative and coordination activities.
- Include plans for the client's discharge and home care needs.
The Planning Process
- Activities:
- Setting priorities.
- Establishing client goals/desired outcomes.
- Selecting nursing interventions and activities.
- Factors to consider in setting priorities:
- Client's health values and beliefs.
- Client's priorities.
- Resources available to the nurse and client.
- Urgency of the health problem.
- Medical treatment plan.
The Nursing Outcome Classification (NOC)
- A taxonomy developed to describe client outcomes that respond to nursing interventions.
- Standardized common nursing language is required in the taxonomy.
- Each NOC outcome is assigned a four-digit identifier and definition.
- Indicators are stated in neutral terms, and each outcome includes a five-point scale to rate the client's status.
Writing Desired Outcomes
- Write goals and outcomes in terms of client responses, not nursing activities.
- Make sure desired outcomes are realistic for the client's capabilities, limitations, and designated time span.
- Ensure that desired outcomes are compatible with the therapies of other professionals.
- Make sure each goal is derived from only one nursing diagnosis.
- Use observable, measurable terms for outcomes.
- Make sure the client considers the goals/desired outcomes important and values them.
Implementing Nursing Interventions
- Action phase in which the nurse performs the nursing interventions.
- Consists of doing and documenting the activities that are specific nursing actions needed to carry out the interventions.
- Skills required:
- Cognitive skills.
- Interpersonal skills.
- Technical skills.
Guidelines for Implementing Nursing Interventions
- Base nursing interventions on scientific knowledge, nursing research, and professional standards of care (evidence-based practice) when these exist.
- Clearly understand the interventions to be implemented and question any that are not understood.
- Adapt activities to the individual client.
- Implement safe care.
- Provide teaching, support, and comfort.
- Be holistic.
- Respect the dignity of the client and enhance the client's self-esteem.
- Encourage clients to participate actively in implementing the nursing interventions.
Evaluating
- A planned, ongoing, purposeful activity in which clients and HCPs determine:
- Client's progress towards achievement of goals or outcomes.
- Effectiveness of the NCP.
- Continuous process.
- Five components of evaluation:
- Collecting data related to the desired outcomes.
- Comparing the data with the desired outcomes.
- Relating nursing activities to outcomes.
- Drawing conclusions about problem status.
- Continuing, modifying, or terminating the nursing care plan.
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Description
Learn about the nursing process, a systematic method of planning and providing individualized nursing care to identify and meet clients' health care needs.
