Nursing Process Review Quiz

Nursing Process Review

• It's a systematic, rational method for planning and delivering individualized nursing care.
• Objectives include identifying patient needs, prioritizing care, maximizing strengths, resolving problems (actual or potential), and promoting health.
• Phases: Assessment, Diagnosis, Outcome Identification, Planning, Implementation, Evaluation.

Assessment

• Systematic and continuous collection, validation, and communication of patient data.
• Data base includes all patient information collected by healthcare professionals to enable effective care planning.
• Primary source is the patient. Secondary sources include: family, friends, medical history, physical examination, lab tests, and other professionals.
• Types: Initial (shortly after admission), Emergency (for physiological/psychological crisis), Time-lapsed (comparing current status to baseline).

Assessment Skills

• Observation
• Interviewing (direct and non-directive)
• Physical Examination Techniques (Inspection, Palpation, Percussion, Auscultation)

Assessment Activities

• Identify priorities based on assessment purpose and patient condition.
• Organize data for systematic collection.
• Establish data using nursing history, records, literature.
• Continuously update, validate, and communicate data.

Nursing Diagnosis

• Second step in the nursing process.
• Clinical judgment about individual, family, or community response to actual or potential health problems.
• Basis for developing nursing interventions.
• Activities: interpret and analyze patient data.
• Types: Actual, Risk, Possible, Wellness, Syndrome.

Types of Nursing Diagnoses

• Actual: Problem already validated by characteristics (e.g., Impaired physical mobility).
• Risk: Vulnerable to developing a problem (e.g., Risk for deficient fluid volume).
• Possible: Suspected problem (e.g., Chronic low self-esteem).
• Wellness: Transition to a higher level of wellness (e.g., Readiness for enhanced self-esteem).
• Syndrome: Cluster of actual or risk diagnoses (e.g., suspected to be present according to certain events).

Differentiating Nursing vs Medical Diagnoses

• Nursing diagnoses focus on unhealthy responses to health and illness, with treatments based on independent nurse practice.
• Medical diagnoses identify diseases, with treatments directed by physicians.

Nursing Planning

• Third step in the nursing process.
• Formulates guidelines for nursing actions to resolve diagnoses and develop a client care plan.
• Activities include establishing priorities, identifying expected outcomes, selecting evidence-based interventions, and communicating the care plan.
• Stages: Initial and Ongoing (to keep plan current by analyzing data).

Implementation

• Carrying out nursing interventions.
• Types: Dependent, Independent, Collaborative.
• Direct: Interaction with clients
• Indirect: Away from client (or behalf of).

Evaluation

• Last phase of the nursing process.
• Assessing the effectiveness of interventions by evaluating whether client goals are met.
• Outcome measures include whether the client achieved desired outcomes, and if interventions need modification.

Discharge Planning

• Best carried out by the nurse who worked most closely with the patient and family.
• Includes four critical elements: established priorities, goals, nursing intervention, documentation.

Physical Assessment

• Collection of objective data directly observed or elicited through examination techniques.
• Includes types and operations of equipment, preparation for examination, and performance of assessment techniques (inspection, palpation, percussion, auscultation).
• Equipment preparation, and preparing oneself and the client for an examination are also part of physical assessment.

Interviewing

• Four phases: Preparatory, Introductory, Maintenance, and Concluding.
• Preparatory involves preparing client and environment, introductory involves establishing rapport and discussing purpose, maintenance focuses on collecting and processing, and concluding confirms understanding and validates plans.
• Techniques include being non-judgmental, maintaining a professional distance, adopting appropriate appearance, observing and managing facial expressions, employing appropriate silence where necessary.

Listening

• The most important skill in gathering valid data.
• Maintain good eye contact, display appropriate facial expression, and an open posture to encourage participation.
• Avoid distracting behaviors and engage in silence to allow clients to reflect and accurately process information.

Communication

• Two main types are nonverbal and verbal.
• Nonverbal includes: appearance, demeanor, facial expression.
• Verbal includes: open-ended (How...), closed-ended (When..), and well-placed phrases.