ATI Chapter 7: Nursing Process
What are independent nursing interventions?
-Autonomous actions taken to benefit clients. They are based on identified problems and healthcare needs, and are within the scope of practice.
How do nurses determine effectiveness of the nursing plan of care?
-Collect data based on what the outcome criteria should be and compare with what actually happened.
What are goals and outcomes?
-Goals = the optimal status of the patient. -Outcomes = observable criteria that determine success or failure of the goal. -Client-centered, observable, measurable, time-limited, agreeable
When does the RN collect data?
-Initial assessment (baseline data) -Focused assessment (gathering data about a specfific problem already identified; routinely part of ongoing data collection) -Ongoing assessment
What are dependent nursing interventions?
-Interventions resulting from a provider's perscription (written, standing, or verbal), or the facility's protocol.
What is a guideline we can use the select priority health problem when presented with multiple clusters of data?
-Maslow's Hierarchy of Human Needs
What if the desired outcome/goal has not been met?
-Modify the plan of care.
What is subjective data?
-Patient symptoms (non measurable); collected during nursing history. -Client feelings, perceptions, descriptions of health status
What is the purpose of implementation?
-Selecting and implementing appropriate interventions using nursing knowledge-base, prioritized care, and planned goals/outcomes to promote/restore/maintain health. Nurses also use interpersonal (COMMUNICATION) skills and technical skills when implementing interventions.
What is objective data?
-Signs a patient displays during a physical examination. -Feel, see, hear, and smell through observation or physcial assessment.
What is the ultimate end product of the planning step of the nursing process?
-THE NURSING PLAN OF CARE!!!!!! (NCP). It provides for quick identification of problems, outcomes, and interventions.
What is the purpose of diagnosing/ analysis?
-Using critical thinking to identify client health problems, interpret/monitor collected data, reach an appropriate nursing judgement about functioning/coping, provides the direction for how nursing care will be provided. -THE DIAGNOSIS CLARIFIES THE EXACT NATURE OF THE PROBLEMS NEEDED TO ACHIEVE THE EXPECTED OUTCOMES OF PATIENT CARE.
Name three methods used to collect data.
-observation -Interviews -medical history -physical examination -lab tests -Interdisciplinary collaboration
Throughout the nursing process. nurses set ___1___, determine client ____2____, and select specific ____3____.
1.Priorities 2.Outcomes 3.Nursing interventions
What are the five steps of the nursing process?
1:Assessment/data collection 2:Diagnose 3:Planning/ Outcome identification/ Goals 4:Implement 5:Evaluate
5. A nursing student is reporting to the clinical instructor about the care she gave to a client. She states: "The client said his leg pain was back, so I checked his medical record, and he last received his pain medication 6 hr ago. The prescription reads every 4 hr PRN for pain, so I decided he needs it. I asked the unit nurse to observe me preparing and administering it. I checked with the client 40 min later, and he said his pain is going away." The instructor should inform the student that she left out which of the following steps of the nursing process? A. Assessmen B. Planning C. Intervention D. Evaluation
A
By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should the nurse do next according to the nursing process? A. Reassess the client to determine the reasons for unsatisfactory pain relief. B. See whether the pain lessens during the next 24 hr. C. Change the plan to ensure that the client achieves adequate pain relief. D. Teach the client about the plan of care for managing his pain.
A
During evaluation, the nurse must gather information about the client to A. identify whether the client outcomes have been met. B. organize resources to proceed with implementing interventions. C. establish client-centered outcomes that are measurable and realistic. D. determine the priority of care and appropriate interventions.
A
What does the nursing process result in?
A comprehensive, individualized, client centered plan of nursing care that nurses can deliver in a reasonable and timely manner.
Define the nursing process.
A five-step sequential but overlapping critical thinking process that systematically achieves optimal client outcomes. It provides a framework through which nurses can apply knowledge, experience, judgement, skills, and established standards to formulate a plan of nursing care.
A nursing instructor is reviewing the steps of the nursing process with a group of nursing students. The students should identify which of the following data as objective? (Select all that apply.) A. Respiratory rate of 22/min with even, unlabored respirations B. "I can only walk three blocks before my legs start to hurt." C. Pain level 3 on a scale of 0 to 10 D. Skin pink, warm, and dry E. Urine output of 300 mL/8 hr F. Dressing clean, dry, and intact
A, D, E, F
What is the purpose of planning/ outcome identification?
Allows the RN to establish priorities and optimal outcomes for care that can be measured and evaluated. -The priorities/outcomes identified will lead the nurse to select interventions that promote/maintain/restore health.
What is discharge planning?
Anticipating and planning for a client's health needs after discharge from the facility.
A nursing instructor is reviewing which actions nurses can initiate without a provider's prescription with a group of nursing students. The students should identify which of the following interventions as nurse-initiated? (Select all that apply.) A. Give morphine sulfate 1 to 2 mg IV every 1 hr as needed for pain. B. Insert an NG tube to relieve a client's gastric distention. C. Show a client how to use progressive muscle relaxation. D. Perform a daily bath after the evening meal. E. Reposition a client every 2 hr to reduce pressure ulcer risk.
C, D, E
What is the purpose of evaluation?
Evaluate client's responses to interventions, and use nursing judgement to determine how well the client's goals/outcomes have been achieved.
T/ F: Another RN tells the nurse, "She told me her shoulder is sore every morning" is an example of objective data.
FALSE. This is an example of subjective data, it is not a patient sign we can feel, see, hear, or smell.
What is the purpose of assessment/ data collection?
Gives us information about a client's health status to identify patient needs and any additional patient data based on findings. FOCUS ON THE PATIENTS RESPONSES TO HEALTH PROBLEMS.
What is the nursing history in relation to assessment?
Identifies patient's health status, strengths, health problems, health risks, and need for nursing care.
Maslow's Hierarchy of Human Needs
In order of priority... 1.PHYSIOLOGIC (Body temp, oxygen, nutrition, fluids, elimination ,sex, shelter)\ 2.SAFETY AND SECURITY (physical and psychological safety) 3.LOVE AND BELONGING. 4.SELF-ESTEEM. 5.SELF-ACTUALIZATION.
What are collaborative interventions?
Interventions carried out in collaboration with other members of the interdiscplinary healthcare team.
What is the initial type of planning?
Nurses essentially do three types of planning. The first of which is A COMPREHENSIVE PLAN OF CARE based on comprehensive assessments, for example, on admisson.
What is ongoing planning?
ONGOING PLANNING occurs THROUGHOUT THE PROVISION OF CARE. The RN obtains NEW INFORMATION/ evaluations and MODIFY/INDIVIDUALIZE plan of care accordingly.
Before modifying the NCP the RN should...
Reassess the client to determine why the desired outcome was not achieved.
T/ F: Client saying "My shoulder is really sore" is a subjective statement.
TRUE.
T/ F: Data the nurse obtains from observation and examination is objective data.
TRUE.
T/ F: Interventions also include those nurses use to minimize risk and respond to unplanned events.
TRUE.
T/ F: The RN collects assessment data prior to establishing interventions.
TRUE.
T/F : Analysis/diagnosing requires nurses to look at data and RECOGNIZE PATTERNS, COMPARE data WITH expected STANDARDS, and arrive at CONCLUSIONS that GUIDE NURSING CARE.
TRUE.
