Chapter 5 Introduction to the Nursing Process

An 82-year-old patient who resides in a nursing home has the following three nursing diagnoses: risk for fall, impaired physical mobility related to pain, and wandering related to cognitive impairment. The nursing staff identified several goals of care, including "The patient will achieve pain relief." Which outcome is related to this goal?

A goal is a broad statement that describes a desired change in a patient's condition or behavior. An expected outcome is a measurable criterion to evaluate goal achievement. In this case, the patient expressing fewer nonverbal signs of discomfort is a measurable criterion to evaluate pain relief.

The nurse is caring for a 50-year-old patient. The patient had the gall bladder removed and it is day two post-surgery. The nurse finds that the patient is uncomfortable and in pain. The nurse also notices some oozing from the site of the surgery. What nursing actions are needed for the patient?

A nurse should apply the nursing process with each patient. The process begins with the assessment and gathering information about the complaint. The assessment helps to arrive at a nursing diagnosis. Based on the nursing diagnosis, the nurse selects the plan of care. It includes the nursing interventions and collaborative care. The nurse can implement the interventions after planning. After implementation, the nurse evaluates if the performed interventions have benefitted the patient and outcomes have been achieved.

The nursing process is an essential component of nursing practice. When using a five-step nursing process, what is the third step?

Planning is the third step of the nursing process. It involves setting priorities, identifying patient-centered goals and expected outcomes, and prescribing individualized nursing interventions. Assessment is the first step, nursing diagnosis is the second, and implementation is the fourth step of nursing process.

While collecting a patient's history, the patient reports to the nurse, "I've had diabetes since I was 10 years old." What is the most accurate way to record this data?

The most accurate way of documenting patient's statements is exactly as the patient says it. The patient's subjective data cannot be measured, felt, or seen by the nurse. The nurse documents the information using the patient's exact words. A dull appearance or a depressed appearance is data perceived by the nurse and is not reported as it may vary from one nurse to another. Tiredness and fatigue may be due to other associated medical conditions. Avoidance of sugary foods is a possible lifestyle adaptation given that the patient is diabetic; however, the nurse cannot assume this adaptation without confirmation from the patient. Inaccurate assumptions are not documented as they may lead to misdiagnosis.

The nurse is caring for a patient at a health care facility. Arrange the steps of nursing process in the order in which it is performed.

The nurse relies on the nursing process to provide effective nursing care to the patient. The first step of the nursing process is assessment. During this step, the nurse gathers primary and secondary data that will enable the nurse to provide effective patient care. The nurse obtains primary data from an interview with the patient. Secondary data are obtained from medical records or from the patient's family members. The second step of the nursing process is the diagnosis. The nurse analyzes, validates, and clusters patient data. This enables the nurse to identify the patient's problems. Each problem is then documented in a standardized language as a specific nursing diagnosis. The third step of the nursing process is planning. During the planning phase, the nurse prioritizes the nursing diagnoses according to the severity of the symptoms and patient preference. The nurse also identifies patient goals that can be evaluated. The fourth step of the nursing process is implementation. The nurse initiates specific nursing interventions and treatments designed to help the patient achieve the established goals. The fifth step of the nursing process is evaluation. During this step, the nurse evaluates the effectiveness of the interventions and may revise the plan of care as required until the established goals are met.

A patient is diagnosed with urinary stress incontinence. The nurse identifies it as which type of diagnosis?

Urinary stress incontinence is an actual diagnosis. Actual diagnosis describes human responses to health conditions or life processes that exist in an individual, family, or community. A risk nursing diagnosis describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community. A health promotion nursing diagnosis is a clinical judgment of a person's, family's, or community's motivation, desire, and readiness to increase well-being. Chronic diagnosis is not a type of nursing diagnosis.

Which step of the nursing process involves the gathering of information while providing patient care?

Assessment, diagnosis, planning, outcome identification, implementation, and evaluation are the steps of the nursing process. Each step of the nursing process has a clear and important purpose and is interdependent. Assessment is the first step and involves the collection of patient information through interviews and physical examination. The nurse collects the data and determines the need for nursing care of the patient. During the planning phase, the nurse identifies short-term and long-term goals based on the nursing diagnosis. Patient-centered outcomes are identified in the planning phase. The patient's data is analyzed, interpreted, and grouped to design the framework of the patient's problems during the diagnosis phase. Implementation involves carrying out the plan of care to achieve the established patient goals.

A nurse is caring for a 79-year-old patient. The patient has been a diabetic for 10 years and comes to the hospital for regular check-ups. The nurse finds that the patient has developed a non-healing wound on the left foot. The nurse is dressing the patient's wound. While performing the dressing, the nurse is unsure about the dilution of the antiseptic solution to be used. What should the nurse do?

Clinical practice protocol is a set of guidelines that helps health care providers to make decisions about appropriate health care. Therefore, the nurse should refer to the clinical practice protocol to know the accurate dilution of the antiseptic solution. Asking her colleague is not reliable. Skipping the use of antiseptic in not ethical and waiting for the health care provider is not necessary in this case.

The nurse is administering oxygen therapy to a patient with severe respiratory distress. The nurse places the patient in the Fowler's position and calls the respiratory therapist to administer a prescribed bronchodilator. Which type of nursing skill is the nurse using in treating this patient?

Collaboration among health care team members is important to promote the patient's health. The primary health care provider prescribes oxygen therapy, the nurse manages the care of the patient and provides comfort and support, and the respiratory therapist administers respiratory treatments. The dynamic nursing process is individualized and based on the assessment findings and patient's changing needs. After a thorough assessment, the nursing care plan is executed in a well-organized, systematic way to meet the needs of the patient. The outcome-oriented nursing process is designed with patient-centered, specific outcomes oriented to meet the patient's individual needs.

What is the final step of the nursing process?

Evaluation is the final step of the nursing process. In the evaluation, the nurse determines if the patient has met the expected outcomes and goals. If goals or outcomes are unmet, the nurse identifies the factors that have hindered the process and makes the changes accordingly. Counseling can be done at any stage of the nursing process. The patient is discharged after being relieved of the health problems. Implementation is performance of the planned implementations.

What should the nurse know about evaluation in the nursing process?

Evaluation is the final step of the nursing process. It is a dynamic, ever-changing, ongoing process. It occurs whenever a nurse has contact with the patient. Other caregivers play a major role in evaluation. They can help the nurse by telling her about the responses of the patient, which reflect the effectiveness of the interventions. If the desired outcomes are not achieved, the care plan is modified. The patient is evaluated repeatedly until the desired outcome goals are achieved.

Arrange the steps in which the nurse would execute an effective nursing care plan.

The nursing care plan includes five steps to initiate and provide patient care. Assessment is the first step in creating a nursing care plan and includes patient history, assessment of cultural and social beliefs, physical examination, and psychological evaluation. The nursing diagnosis is the clinical decision made by the nurse about the patient or the family members based on actual or potential health issues. During the planning phase, the nurse sets a patient-centered goal, identifies the outcomes, and plans the nursing interventions accordingly. Implementation follows planning and involves carrying out the planned interventions to facilitate reaching established patient goals. During the fifth step, the nurse evaluates the progress of the patient in reaching the identified goals. If new problems are identified, the nurse would start the process again.