Podcast
Questions and Answers
Which of the following best describes the nursing process?
Which of the following best describes the nursing process?
- A research methodology used to validate nursing theories.
- A flexible framework, adaptable to various healthcare institutions and patient age groups. (correct)
- A rigid set of protocols applicable only in acute care settings.
- A task-oriented approach focused on completing medical orders.
How did NANDA contribute to the standardization of nursing diagnoses?
How did NANDA contribute to the standardization of nursing diagnoses?
- By developing a structured terminology for nursing diagnoses. (correct)
- By establishing a universal system for documenting patient vital signs.
- By defining the scope of practice for registered nurses.
- By creating standardized care plans for common medical conditions.
What is the primary importance of prioritizing nursing diagnoses?
What is the primary importance of prioritizing nursing diagnoses?
- To ensure all nursing interventions are completed within the shift.
- To comply with hospital accreditation standards.
- To efficiently allocate nursing resources.
- To address immediate threats to the patient's well-being first. (correct)
What characterizes the assessment phase of the nursing process?
What characterizes the assessment phase of the nursing process?
A patient reports feeling short of breath. How would the nurse classify this data during the assessment phase?
A patient reports feeling short of breath. How would the nurse classify this data during the assessment phase?
Which activity exemplifies the 'organizing data' step in the nursing assessment?
Which activity exemplifies the 'organizing data' step in the nursing assessment?
A nurse obtains conflicting blood pressure readings from two different devices. Which action should the nurse take?
A nurse obtains conflicting blood pressure readings from two different devices. Which action should the nurse take?
In the context of data collection, what does 'olfaxation' refer to?
In the context of data collection, what does 'olfaxation' refer to?
A patient is diagnosed with 'Risk for Impaired Skin Integrity.' What does this indicate?
A patient is diagnosed with 'Risk for Impaired Skin Integrity.' What does this indicate?
Which element is essential in an actual nursing diagnosis but not in a risk diagnosis?
Which element is essential in an actual nursing diagnosis but not in a risk diagnosis?
A nurse identifies multiple nursing diagnoses for a patient. Which diagnosis should be addressed first?
A nurse identifies multiple nursing diagnoses for a patient. Which diagnosis should be addressed first?
A patient is admitted with pneumonia and has difficulty breathing. Which nursing diagnosis is most appropriate?
A patient is admitted with pneumonia and has difficulty breathing. Which nursing diagnosis is most appropriate?
What is the key difference between the nursing diagnosis and the medical diagnosis?
What is the key difference between the nursing diagnosis and the medical diagnosis?
During which phase of the nursing process are goals and outcomes of patient care determined?
During which phase of the nursing process are goals and outcomes of patient care determined?
Why is patient involvement crucial during the planning phase?
Why is patient involvement crucial during the planning phase?
What is the primary focus of the implementation phase of the nursing process?
What is the primary focus of the implementation phase of the nursing process?
Which nursing action exemplifies the implementation phase of the nursing process?
Which nursing action exemplifies the implementation phase of the nursing process?
Why is documenting all nursing interventions important?
Why is documenting all nursing interventions important?
What is the main purpose of the evaluation phase in the nursing process?
What is the main purpose of the evaluation phase in the nursing process?
If the goals set in the care plan are not achieved, what is the next appropriate step?
If the goals set in the care plan are not achieved, what is the next appropriate step?
Which factor might lead to a failure in achieving the goals of a nursing care plan?
Which factor might lead to a failure in achieving the goals of a nursing care plan?
What does it mean for the nursing process to be 'cyclical'?
What does it mean for the nursing process to be 'cyclical'?
During the assessment phase, a nurse uses inspection, palpation, and auscultation. Which data collection method are they employing?
During the assessment phase, a nurse uses inspection, palpation, and auscultation. Which data collection method are they employing?
Which of the following best explains why the nursing process is described as 'systematic'?
Which of the following best explains why the nursing process is described as 'systematic'?
In 1955, which nursing pioneer used it as the 'Nursing Process System'?
In 1955, which nursing pioneer used it as the 'Nursing Process System'?
Early models of the nursing process involved how many steps before evolving to the current five-step model?
Early models of the nursing process involved how many steps before evolving to the current five-step model?
If a patient has a NANDA nursing diagnosis of 'Readiness for Enhanced Parenting', what type of diagnosis is this?
If a patient has a NANDA nursing diagnosis of 'Readiness for Enhanced Parenting', what type of diagnosis is this?
The nursing process ensures that care is...
The nursing process ensures that care is...
Which component of the nursing process involves setting priorities?
Which component of the nursing process involves setting priorities?
What does data validation during data collection ensure?
What does data validation during data collection ensure?
Why should data be recorded realistically and without interpretation?
Why should data be recorded realistically and without interpretation?
During assessment, which source provides subjective data?
During assessment, which source provides subjective data?
Which of these would be the FIRST action when using the nursing process?
Which of these would be the FIRST action when using the nursing process?
According to the material supplied, which could result in a failure to achieve the goals of a nursing care plan?
According to the material supplied, which could result in a failure to achieve the goals of a nursing care plan?
In the phases of the nursing process, the goals are set during:
In the phases of the nursing process, the goals are set during:
In what phase is is the care plan carried out?
In what phase is is the care plan carried out?
Which one of these best describes the point of the evaluation phase of the nursing process?
Which one of these best describes the point of the evaluation phase of the nursing process?
If a goal is not achieved, what should be done?
If a goal is not achieved, what should be done?
Which best describes the term 'cyclical,' as it relates to the nursing process?
Which best describes the term 'cyclical,' as it relates to the nursing process?
A patient reports feeling anxious and having difficulty breathing. According to the nursing process, what type of nursing diagnosis would the nurse prioritize?
A patient reports feeling anxious and having difficulty breathing. According to the nursing process, what type of nursing diagnosis would the nurse prioritize?
If the nurse identifies that a patient is at risk for falls due to impaired mobility, which component is missing from this risk nursing diagnosis?
If the nurse identifies that a patient is at risk for falls due to impaired mobility, which component is missing from this risk nursing diagnosis?
What is the primary reason for the nursing process to be considered 'systematic'?
What is the primary reason for the nursing process to be considered 'systematic'?
A nurse assesses a patient and documents the following data: 'Patient is restless, blood pressure is 160/90, and heart rate is 110 bpm.' Which part of the nursing process does this action represent?
A nurse assesses a patient and documents the following data: 'Patient is restless, blood pressure is 160/90, and heart rate is 110 bpm.' Which part of the nursing process does this action represent?
What does the 'etiology' component of a nursing diagnosis refer to?
What does the 'etiology' component of a nursing diagnosis refer to?
A nurse is using 'olfaxation' during a patient assessment. What sort of information is the nurse trying to obtain?
A nurse is using 'olfaxation' during a patient assessment. What sort of information is the nurse trying to obtain?
During the planning phase, the nurse collaborates with the patient to set goals. What is the primary reason for this collaboration?
During the planning phase, the nurse collaborates with the patient to set goals. What is the primary reason for this collaboration?
A patient has a nursing diagnosis of 'Ineffective Airway Clearance related to excessive mucus.' Which intervention would directly address the etiology of this problem?
A patient has a nursing diagnosis of 'Ineffective Airway Clearance related to excessive mucus.' Which intervention would directly address the etiology of this problem?
Which action demonstrates the 'evaluation' phase of the nursing process?
Which action demonstrates the 'evaluation' phase of the nursing process?
A nurse implements a care plan for a patient with a diagnosis of 'Anxiety.' After one week, the patient reports no reduction in anxiety levels. What should the nurse do first?
A nurse implements a care plan for a patient with a diagnosis of 'Anxiety.' After one week, the patient reports no reduction in anxiety levels. What should the nurse do first?
Flashcards
Nursing Process
Nursing Process
A systematic method to identify health care needs and provide individual care.
5 Steps of Nursing Process
5 Steps of Nursing Process
Assessing, Diagnosing, Planning, Implementation, and Evaluation
Purpose of Nursing Process
Purpose of Nursing Process
To identify individual health needs, set priorities and goals, implement nursing interventions, and evaluate effectiveness of care.
Assessment in Nursing
Assessment in Nursing
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Subjective Data
Subjective Data
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Objective Data
Objective Data
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Data Collection Methods
Data Collection Methods
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Organizing Data
Organizing Data
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Validating Data
Validating Data
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Nursing Diagnosis
Nursing Diagnosis
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Types of nursing diagnosis
Types of nursing diagnosis
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Nursing Diagnosis Components
Nursing Diagnosis Components
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Diagnosis (ANA 1991)
Diagnosis (ANA 1991)
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Documenting Diagnosis
Documenting Diagnosis
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Planning definition
Planning definition
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Planning Process in Nursing
Planning Process in Nursing
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Implementation
Implementation
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Implementing care
Implementing care
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Evaluation Definition
Evaluation Definition
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Evaluating importance
Evaluating importance
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Study Notes
The Nursing Process
- Conducted by Assist. Prof. Dr. Funda Karaman
Objectives of the Nursing Process
- Defining the purpose
- Learning the steps
- Explaining the steps with a sample plan
- Applying the process
About the Nursing Process
- A systematic method used to identify healthcare needs
- Designed for both healthy and sick individuals
- Aims to provide individual care
History of the Nursing Process
- First used in 1955 by Lydia Hall
- Known as the "Nursing Process System"
- Dorothy Johnson(1959), Idea Jean Orlanda (1961) and Ernestine Wiedenbach (1963) handled the process in three stages
- Yura and Walsh (1967), Kartz (1979), McFarlene and Castledine (1982) defined the process in four steps
NANDA's Role
- In 1973, Kritina Gebbie and Mary Am Lavin focused on nursing diagnosis
- They organized a conference to classify nursing diagnoses
- After the first meeting of the North American Nursing Diagnosis Association (NANDA) in 1974 Gebbie and Lavin added nursing diagnosis to the nursing process
- NANDA created the "Nursing Diagnosis Terminology" in 1982
- Became "international" in 1992 to represent international participation
- Universally used across all nursing branches
Features of the Nursing Process
- Universal: Used in all health institutions and age groups
- Cyclical Continuous and dynamic
- Patient-centered in care
- Ensures scientifically planned and systematic care
- Provides individual and systematic evaluation
- Increases critical thinking, decision-making, and problem-solving abilities
- Improves interpersonal, technical, and intellectual skills
Purpose of the Nursing Process
- Identifying individual health needs
- Determining individual priorities
- Determining goals of care
- Identifying and implementing nursing interventions
- Evaluating the effectiveness of nursing care
The 5 Steps
- Assessing
- Diagnosis
- Planning
- Implementing
- Evaluating
I. Assessment
- Collecting data
- Organizing data
- Validating data
- Documenting data
Collecting Data
- Data is grouped as subjective and objective
- Subjective data: Data expressed verbally by the patient and family
- Objective data: Includes data collected through physical assessment, diagnostic procedures, and lab results
- Examples of subjective data: the patient says "I'm getting short of breath" or "I'm afraid of having surgery"
- Examples of objective data: blood pressure 90/50 mmHg, apical pulse 106/min, vomited 100cc of green color
Data Collection Methods
- Observation.
- Interview.
- Physics assessment
- Inspection (observation)
- Auscultation (hearing)
- Palpation (manual examination)
- Percussion (hitting with fingers)
- Olfaxation (by smelling)
Data Sources
- Healthy/sick individual
- Family member
- Support people
- Patient Records
- Other health professionals
- Diagnosis and lab results
- Previous records
Organizing Data
- Written or computerized recording formats are used to organize data
- Data is collected and recorded with the data collection form
Validating and Documenting Data
- To ensure data collected is completed, real, and correct
- Data records must be accurate, timely, and include all info regarding patient health status
- Data should be recorded realistically and without interpretation
II. Diagnosis
- Nursing diagnosis describes the patient’s actual and potential response to a health problem.
- Nurses analyzes diagnostic data to determine nursing diagnosis (ANA, 1991)
Types of Nursing Diagnoses
- Actual (problem-focused)
- Risk (potential)
- Health promotion/wellness
Types of Nursing Diagnosis Explained
- Actual problem: related to a patient's existing problem, there will be signs and symptoms. Example: ineffective breathing pattern
- Risk (potential) diagnosis: no current problem, might develop if no action is taken. Example: risk of impaired skin integrity associated with immobilization due to pelvic fracture.
- Wellness/health promotion: used to identify how to help improve the health of a patient. Example: the potential for parental role development
NURSING DIAGNOSIS Components
- Identification of the problem
- Determination of etiology (cause of the problem/related factors)
- Identification of symptoms (signs-symptom/descriptive feature)
- NOTE: There are no signs-symptoms in risk diagnosis
DOCUMENTATION OF NURSING DIAGNOSIS
- Nursing diagnoses are listed and the order of priority is determined
- this should be done in the patient care plan
- Actual diagnoses are handled first, then the risk diagnoses should be handled
Examples of Nursing Diagnoses
- prioritize these nursing diagnoses in this order: ineffective respiratory pattern, chronic pain, oral mucous membrane, infection-risk for, falls-risk for
III. Planning
- A conscious and systematic phase of the nursing process, including decision-making and problem-solving.
- Necessary interventions are determined to prevent, reduce, or eliminate the patient's health problems
The Planning Process
- Determination of priorities (action that needs to be taken urgently)
- Determining the goals/desired outcomes of patient care
- Selection of initiatives
- Writing the care plan
IV. Implementing
- The implementation phase is the implementation of the care plan to achieve the goal specified in the care plan.
- This phase of the nursing process is known as the delivery of care
- Providing care safely and effectively depends on professional knowledge, experience, and the ability to establish positive interpersonal relationships
- All applications made are recorded
V. Evaluating
- The most important stage of the nursing process
- Determine the goals
- If not, the problem is handled again and new interventions are planned
- The nursing process begins again from the first step
Reasons Goals Aren't Acheived
- There isn't enough data
- Inappropriate diagnosis
- Unrealistic goals
- Wrong approach
- Interventions don't fit the patient situation
- Unfinished initiatives
- Unexpected changes in the patient's condition
Case Study: Hyperthermia
- Nursing Diagnosis: Hyperthermia
- Etiology: Related to decreased ability to perspire
- Factors: Terkere
- Goal Planning: Identify risk factors for hyperthermia and reduce risj
- Interventions: Monitor intake and output, apply cold application, assess weather, remove blankets, teach fluid intake,
- Evaluation: not achieved
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