Fundamentals Chapter 5
What are the steps of the nursing process?
Assessment, diagnoses, planning, implementation, evaluation ....ADPIE
Describe the steps of the nursing process:
Assessment: patient care data are gathered Diagnosis: patient data are analyzed to identify patient problems and then are stated as specific nursing diagnosis. Planning: the nurse prioritizes the nursing diagnoses and identifies goals with specific outcome identification. Implementation:initiating specific nursing interventions designed to help achieve established goals. Evaluation: the nurse determines a goal attainment, the effectiveness of interventions and whether the plan of care should be discontinued, continued, or revised.
What is the primary purpose of the nursing diagnoses?
Communicating patient needs
Objective Data:
Consists of observable information that the nurse gathers on the basis of what can be seen, measured, or tested.
Which nursing action is critical before delegating interventions to another member of the healthcare team?
Know the scope of practice for the other team member
What action should the nurse take regarding a patient's plan of care if the patient appears to have met the short-term goal of urinating within 1 hour after surgery?
Monitor patient urine output to evaluate the need for the current plan of care
What is the purpose of the nursing process?
Organizing the ways nurses think about patient care..."think like a nurse"
A patient comes to the emergency department complaining of nausea and vomiting. What should the nurse ask the patient about first?
Severity and duration of the nausea and vomiting.
An alert, oriented patient is admitted to the hospital with chest pain. Who is the best source of primary data on this patient?
The patient
what is the nursing process?
The systematic method of critical thinking used by professional nurses to develop individualized plans of care and provide care for patients.
What is the time period for a short term goal?
approximately 1 week
On what premise is a nursing diagnosis identified for a patient?
clustered data ?
What is coordinated team-based patient care called?
collaborative care
Evaluation:
focuses on the patient and the patient's response to nursing interventions and goal or outcome attainment.
What is nursing diagnosis?
identifies an actual or potential problem or response to a problem
A patient reports feeling tired and complains of not sleeping at night. What action should the nurse perform first?
identify the reason that the patient is unable to sleep
Outcome identification:
involves listing behaviors or observable items that indicate attainment of a goal
What is the significance of the cyclic and dynamic nature of the nursing process?
nurses continually reassess patients, revise care as needed, and evaluate whether goal are being met.
What should be the primary focus for nursing interventions?
patient needs
implementation:
the initiation of appropriate interventions designed to meet the unique needs of each patient
What is "planning"?
the nurse priorities a patient's various nursing diagnoses, establishes short- and long- term goals, chooses outcome indicators, and identifies interventions to address patient goals.
What is assessment?
the organized and ongoing appraisal of a patient's well-being
Define the nursing process:
the scientific method through which professional nurses systematically identify and address actual or potential patient problems...ADPIE
what is the time period for a long-term goal?
weeks to months
