Chapter 2: Nursing Process

List three parts of a nursing diagnostic statement.

P: Name of the health-related issue or problem as identified in the NANDA-I list E: Etiology (its cause) S: Signs and symptoms also called defining characteristics

Discuss appropriate circumstances for short- and long-term goals.

Short-term goals: outcomes achievable in a few days to 1 week. For clients with acute health problems. Long-term goals: outcomes that take weeks or months to accomplish. For clients with chronic health problems.

Explain principles of setting priorities for nursing care

· Change-of-shift report should give clues as to the priority of each action to be implemented · Priorities of care may need to be altered if patient's condition becomes more acute

List factors to consider when setting priorities

· Problems ranked according to their importance · Physiologic needs for basic survival take precedence (i.e., airway and circulation) · After physiologic needs are met, safety problems take priority · Every nurse must attempt to look at each patient holistically, keeping psychosocial needs in mind while working on physical problems

Discuss three outcomes that result from an evaluation.

· The client has reached the goals · The client has made some progress · The client has made no progress

Apply the critical thinking process to a real-life problem

•Goal is to avoid having your decision cause injury to anyone •With critical thinking skills, you can weigh many factors and skillfully solve problems, making good decisions a majority of the time •Operating in critical thinking mode while pursuing nursing studies helps develop clinical judgment needed to practice safe nursing

Identify four ways to document a plan of care.

1. written by hand 2. standardized on printed forms 3. computer generated 4. based on an agency's written standards or clinical pathways.

List five steps/components in the nursing process.

ADPIE 1. Assessment-The nurse collects patient health data. 2. Diagnosis-The nurse analyzes the assessment data to determine diagnoses. The nurse identifies expected outcomes individualized to the patient. 3. Planning-The nurse develops a plan of care that prescribes interventions to attain expected outcomes. 4. Implementation-The nurse implements the interventions identified in the plan of care. 5. Evaluation-The nurse evaluates the patient's progress toward attainment of outcomes. The construction of a plan of care for the patient is a collaborative process among the nurse, the patient, and other health team members. Patient input during the planning stage results in more success with the plan of care. We use the nursing process (other methods) to organize tasks in daily life and don't even realize it.

Describe seven distinct characteristics of the nursing process. State what "critical thinking" means. Discuss the use of critical thinking in nursing

Critical thinking- the process of objective reasoning; analyzing facts to reach a valid conclusion 1. Within the legal scope of nursing 2. Based on knowledge 3. Planned 4. Client centered 5. Goal directed 6. Prioritized 7. Dynamic

Differentiate between database, focus, and functional assessments.

Database assessment- initial information about the client's physical, emotional, social, and spiritual health use, is lengthy and comprehensive. T Focus assessment- is information that provides more details about specific problems and expands the original database. (focuses on a specific problem) - ongoing & continuous. In a focused assessment, data are collected only for areas with obvious problems, deviations, or alterations, leading to quick implementation of care. This approach is useful when the patient is in acute distress. Functional assessment- is a comprehensive evaluation of a client's physical strengths and weaknesses. Formulated by Mary Gordon. It provides a reference for comparing all future data and provides the evidence used to identify the client's initial problem. Basic needs assessment-based on Maslow's hierarchy of basic needs.

Identify two learning strategies used by educators to help students implement the nursing process.

Nursing care plan- written assignments on a standardized worksheet that contains a column for nursing diagnoses, outcome criteria, nursing interventions, and their rationale for each assigned client. Concept Mapping- (also known as care mapping) is a method of organizing information in graphic or pictorial form. It is created by identifying a main subject with interconnected links to related components.

Distinguish between a nursing diagnosis and a collaborative problem.

Nursing diagnosis- is a health issue that can be prevented, reduced, resolved, or enhanced through independent nursing measures. It is an exclusive nursing responsibility. (problem focus, risk diagnosis, syndrome diagnosis, health promotions) Collaborate problem- The role of the nurse is to monitor to detect the complication(s) and, if detected, manage the complication cooperatively with nurse- and physician-prescribed interventions. ALWAYS THINK "MONITORING FOR COMPLICATIONS"

Types of Data

Objective data are observable and measurable facts and are referred to as signs of a disorder (ex. a client's blood pressure measurement) Subjective data consist of information that only the client feels and can describe, and are called symptoms. (ex. pain.) written in quotes.

Describe the rationale for setting priorities.

Since many clients' problems take time to resolve, it is important to determine which problems require the most immediate attention. This is done by setting priorities. Prioritization involves ranking, from those that are most serious or immediate to those of lesser importance.

Describe the information that is documented in a plan of care.

Standardized care plans are preprinted. Both computer-generated and standardized plans provide general suggestions for managing the nursing care of clients with a particular problem. It is up to the nurse to transform the generalized interventions into specific nursing orders and to eliminate whatever is inappropriate or unnecessary.

Define the term nursing process. Explain the use of the nursing process

The nursing process is an organized sequence of problem-solving steps used to identify and manage the health problems of clients The nursing process is used: *Used as a tool identify patients' problems and an organized method to meet patients' needs *Used to identify and manage the health problems of clients *Accepted standard for clinical practice: American Nurses Association (ANA) *Framework for nursing care

Identify four sources of assessment data. ASSESSMENT - FIRST STEP IN THE PROCESS

The primary source of information is the client (physical assessment and interview). Secondary sources include the client's family, reports, test results, information in current and past medical records, and discussions with other health care providers.

Identify ways to improve critical thinking skills

•Effective reading •Effective writing •Attentive listening •Effective communicating