Podcast
Questions and Answers
What is the primary purpose of the nursing process?
What is the primary purpose of the nursing process?
Which phase of the nursing process involves gathering information about a patient?
Which phase of the nursing process involves gathering information about a patient?
Which type of assessment is conducted after a patient's admission to establish a complete data base?
Which type of assessment is conducted after a patient's admission to establish a complete data base?
What characteristic describes the nursing process as being changeable and responsive to new information?
What characteristic describes the nursing process as being changeable and responsive to new information?
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In which assessment type might a nurse conduct hourly assessments of fluid intake and output?
In which assessment type might a nurse conduct hourly assessments of fluid intake and output?
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What type of data can be described or verified only by the affected person?
What type of data can be described or verified only by the affected person?
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Which of the following is NOT a method of data collection in the assessment process?
Which of the following is NOT a method of data collection in the assessment process?
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Which data source is considered primary in a health assessment?
Which data source is considered primary in a health assessment?
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What is the correct order of techniques used in a complete physical examination?
What is the correct order of techniques used in a complete physical examination?
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Which of the following describes palpation in the context of physical examination?
Which of the following describes palpation in the context of physical examination?
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Study Notes
Nursing Process Overview
- The nursing process is a systematic, rational method for planning and providing care.
- Its purpose is to identify clients' health status, actual or potential health problems.
- It establishes plans to meet identified needs to deliver specific nursing interventions to address those needs.
Phases of the Nursing Process
- The five phases are assessment, diagnosis, planning, implementation, and evaluation.
- Each phase is closely interrelated and affects the others.
Characteristics of the Nursing Process
- The nursing process is cyclical and dynamic.
- It is client-centered.
- It is an adaptation of problem-solving.
- Decision-making is involved in every phase.
- It is interpersonal and collaborative.
- It employs critical thinking skills.
Assessment
- Assessment is the systematic and continuous collection, organization, validation and documentation of data.
- It aims to prevent omitting significant data and reflect changing health status.
- Types of assessment include initial, problem-focused, emergency, and time-lapsed assessments.
Types of Assessment
- Initial Assessment: Performed after admission to identify problems, reference, and compare with future data (e.g., nursing admission assessment).
- Problem-focused Assessment: Ongoing process integrated with nursing care, focusing on specific identified problems, such as hourly assessment in Intensive Care Units.
- Emergency Assessment: Used during crises (physiological or psychological) to identify life-threatening problems. Examples include assessing airway, breathing, and circulation during cardiac arrest.
- Time-lapsed Assessment: Carried out months after initial assessment to compare current status with previous baseline data, such as reassessing functional health patterns in outpatient settings.
Assessment Activities
- Collecting Data: The process of gathering client health status information.
- Data Base: All client information, including nursing health history, physical assessments, care provider history and physical examinations, laboratory and diagnostic test results.
Types of Data
- Subjective Data (Symptoms): Information described/verified only by the affected person including sensations, feelings, values, beliefs, attitudes and perceptions of personal health status. Examples include itching, pain, and worry.
- Objective Data (Signs): Information that can be observed, measured or tested against standards (e.g., discoloration of skin, blood pressure reading).
Source of Data
- Primary Source: The client.
- Secondary Sources: Family, support persons, other healthcare professionals, records, reports, laboratory and diagnostic analyses (indirect).
Methods of Data Collection
- Observation: Gathering information using senses. (Vision, Smell, Hearing).
- Interview: Planned communication/conversation.
- Examination: Diagnostic procedures and lab investigations
- Physical Examination Techniques:
- Inspection
- Palpation
- Percussion
- Auscultation
Data Analysis
- Organize data.
- Validate data (double-check accuracy).
- Document data.
Nursing Diagnosis
- Definition: Clinical judgment about individual, family, or community responses to actual and potential health problems/life processes.
- NANDA (North American Nursing Diagnosis Association): The organization that provides a working definition of nursing diagnosis.
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Types:
- Actual Diagnosis: Client problem present during assessment (e.g. ineffective breathing pattern, anxiety).
- Risk (Potential) Diagnosis: No problem exists, but risk factors are present, indicating the likelihood of problem development (e.g., risk for infection)
- Health Promotion Diagnosis: Relates to the client's readiness to improve their health condition. (e.g. readiness for enhanced nutrition).
Components of a NANDA Diagnosis
- Problem (diagnostic label): Describes health problem (e.g., Deficient Knowledge, Medication).
- Etiology (related factors/risk factors): Identifies probable causes of problems, guiding therapy.
- Defining Characteristics (Signs & Symptoms): Cluster of signs and symptoms that indicate a health problem in actual diagnosis. No signs or symptoms are present in risk nursing diagnoses.
- Statement Format: The diagnostic statement follows a “PES” format (Problem-Etiology-Signs).
Planning
- Formulating client goals.
- Designing nursing interventions.
- Prevent, reduce, or eliminate client health problems.
Types of Planning
- Initial Planning
- Ongoing Planning
- Discharge Planning
Maslow's Hierarchy of Needs
- This hierarchy prioritizes human needs, beginning with physiological requirements (air, water, food, shelter). Higher levels include safety, love/belonging, esteem, and self-actualization.
Guidelines for Writing Nursing Care Plans
- Date and sign the plan.
- Use standardized medical or English symbols and key words.
- Specify the timing of an intervention
- Refer to guidelines.
Ongoing Interventions and Plans
- Ensure plan covers ongoing assessment.
- Include collaborative activities.
- Include discharge/home care plans.
Nursing Interventions
- Interventions are any treatments performed by nurses to improve patients' health.
Implementation
- Implementation includes doing and documenting activities.
- This involves performing nursing interventions and documenting implemented activities.
Evaluation
- Evaluation is a planned, ongoing, purposeful activity.
- It determines the client's progress toward achieving goals; it also evaluates the effectiveness of the care plan.
Evaluation Contents
- Identify evaluation criteria and standards.
- Collect evaluation data.
- Interpret and summarize the findings.
- Document findings.
- Care plan revision can include:
- Terminating the care plan.
- Modifying the care plan.
- Continuing the care plan.
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Description
Explore the systematic approach to nursing care through this quiz on the nursing process. Understand the five key phases: assessment, diagnosis, planning, implementation, and evaluation. Each phase plays a crucial role in providing optimal patient care.
