Nursing Process Overview Quiz

Assessing

• Assessing is continuous collection, organization, validation, and documentation of data in nursing.
• Completeness of assessment impacts the accuracy of subsequent nursing steps.
• Four types of assessments include:
  • Initial assessment: Establishes a complete baseline after admission.
  • Problem-focused assessment: Ongoing, evaluates specific health issues.
  • Emergency assessment: Conducted during crises to identify life-threatening problems.
  • Time-lapsed reassessment: Compares current status to previous baseline after some months.

Assessment Steps

• Steps consist of collecting diverse data, validating information, organizing findings, and identifying patterns.
• Inferences are interpretations by the nurse based on objective and subjective cues observed.
• Validating data is essential when discrepancies between subjective and objective information arise.

Documenting Data

• Accurate documentation of client data is crucial and should avoid personal interpretations.
• Documentation should be factual; subjective reports must be recorded verbatim to maintain accuracy.
• Example: Instead of stating "appetite good," record actual food intake to avoid subjective bias.

Identifying Health Problems, Risks, and Strengths

• After data analysis, strengths and problems are collaboratively identified by the nurse and client.
• The nurse evaluates whether a problem is nursing, medical, or collaborative.
• Strengths may include resources and coping abilities relevant to health.

Formulating Diagnostic Statements

• Nursing diagnoses typically comprise two or three part statements addressing client responses and related factors.
• Basic two-part statement includes:
  • Problem (P): Client’s response (NANDA label).
  • Etiology: Related factors influencing the problem.

Implementing

• Implementation involves reassessing the client and determining nursing interventions required.
• Nurses must document outcomes, interventions performed, and client responses.

Evaluating

• Evaluation determines whether client goals are met, partially met, or unmet.
• Reasons for unmet goals may include incomplete initial data, unrealistic goals, or inappropriate interventions.
• Evaluation is an ongoing process throughout nursing care, guiding future actions and modifications.

Example Nursing Diagnosis: Ineffective Airway Clearance

• Related to:
  • Tracheal bronchial inflammation, edema formation, increased sputum production, pleuritic pain, and decreased energy.
• Evidenced by:
  • Abnormal respiratory rate and depth, abnormal breath sounds, dyspnea, cyanosis, and ineffective cough.
• Desired outcome:
  • Display patent airway, effective breath sounds, and absence of dyspnea or cyanosis.