overview of the nursing process (potter)
A patient comes to the emergency department complaining of fever and diarrhea. What should the nurse ask the patient first?
"What is the severity and duration of your fever and diarrhea?"
The American Nurses Association (ANA) (1973) identified the five steps of the nursing process:
(1) assessment, (2) diagnosis, (3) planning (including outcome identification), (4) implementation, and (5) evaluation.
assessment
A pregnant patient is hospitalized at 27 weeks of gestation due to chest pain and shortness of breath. A nurse assesses the patient and observes consistent high blood pressure readings. The nurse plans to assess the patient on an ongoing basis as the other steps of the nursing process are implemented. Meanwhile, the health care provider conducts a medical assessment and determines a medical diagnosis of blood clots.
assess
Gather data through observation, interviews, and physical assessment. Collect data for individual patients through various methods such as physical examination, patient health history, chart review, or lab test review. Collect data for communities or families through observations, interviews, or documentation review.
Stella Jones, RN, reassesses a patient one hour after giving morphine for the patient's pain. The patient states that she is still in horrible pain, eliciting a response of 8 out of 10. What would be the most appropriate intervention?
Giving additional breakthrough pain medication is the most appropriate intervention for controlling pain.
Which subcategory of planning is recognized by professionals and educators as part of the traditional five-step nursing process?
Outcome identification Outcome identification is a part of the nursing process. Most nursing professionals and educators recognize outcome identification as part of the planning step of the traditional five-step nursing process.
Which option exemplifies a short-term goal the nurse may identify during the planning step of the nursing process?
Patient verbalizes a pain level of 4 or 5, out of 10, within 2 hours of receiving prescribed pain medication. A time period of 2 hours is an appropriate choice for a short-term goal. This time period is the shortest of all the answer choices.
plan
Prioritize diagnoses and set goals and outcomes for each diagnosis. Review nursing diagnoses and prioritize them. Plan realistic, measurable, and patient-centered goals based on nursing diagnoses. Identify clear outcome criteria for each diagnosis.
Which best describes the diagnosis step of the nursing process?
The nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers. The diagnosis step of the nursing process is when the nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.
implementation
The nurse implements nursing measures to ensure that the patient rests, eats a proper diet, and gets an appropriate amount of exercise. Each day, for five days, the nurse conducts regular patient education to teach the patient to self-inject heparin. Soon the patient demonstrates the effectiveness of the teaching by successfully self-injecting heparin, and by making proper dietary choices that will not interfere with the blood-thinning effects of the medication.
diagnosis
The nurse selects and individualizes nursing diagnoses that include addressing patient comfort, gas exchange, activity intolerance, dietary needs, and self-care. The nurse uses these nursing diagnoses as the basis for the patient's care plan.
organized
When nurses follow the steps of the nursing process, patient care is well organized and comprehensive. The nursing process provides a standardized and systematic method of addressing patient needs, and it is understood by nurses worldwide.
The _________characteristic of the nursing process is that nursing care plans can be developed for patients in any care setting, as well as for targeted populations and communities.
adaptable
The _____________ characteristic of the nursing process describes when nurses ask questions and demonstrate the use of critical thinking for each step.
analytical
Which step of the nursing process does a nurse use when finding blood pressure of 180/75, a heart rate of 90, and a patient complaint of chest pain?
assessment
Dorothy E. Johnson (1959)
believed that nursing should focus on the patient as an individual, instead of the disease. She identified two areas that nurses could concentrate on to bring the patient back to a state of mental and physical balance: reducing stressful stimuli and supporting natural and adaptive processes.
Ida Jean Orlando (1961)
suggested that nurses use interpersonal relationships to meet the needs of the patient as defined by the patient, not as defined by the nurse. This approach supported the patient as a member of the health team.
implement
Follow planned interventions. Implement specific nursing interventions to achieve goals.
What analytical questions are asked at each step in the nursing process?
"Is the data collection thorough and accurate?" "Have all underlying factors been addressed in the care plan?" "Could interventions impact the patient negatively?"
A nurse is preparing a presentation to the unit on ANA, the organization that identified the five steps of the nursing process. What does ANA stands for?
American nurses association
diagnose
Analyze, validate, and cluster data to identify patient problems. Analyze data collected in assessment to identify patient problems. State each problem in standardized language as a specific nursing diagnosis. The nursing diagnosis provides the basis for selection of nursing interventions.
evaluation
At 30 weeks gestation, the patient is ready for discharge. The nurse coordinates with the entire health care team to monitor and continually evaluate the effectiveness of the plan of care. Regular blood tests and office visits are maintained to assess heparin levels and the resolution of the blood clots. The patient's blood pressure, diet, and lifestyle habits are also continually evaluated.
analytical
At each step in the nursing process, analytical questions must be asked: Is the data collection thorough and accurate? Are outcomes specific and realistic? Have all underlying factors been addressed in the care plan? Could any nursing interventions impact the patient negatively? Are the interventions safe? Does new data indicate that the care plan should be modified
What does the term "dynamic nature" of the nursing process refer to?
Change over time in response to the patient's needs The dynamic nature refers to the way the process changes to meet the patient's needs.
collaborative
Collaboration among several members of the health care team (such as the primary care provider, therapists, and social workers) is often required to adequately address patient needs. Nurses may incorporate actions by the patient or family to address patient goals, particularly if the patient is not acutely ill or requires home care.
What is the primary purpose of the nursing diagnosis?
Communicating patient needs
evaluate
Determine effectiveness of implemented patient care plan. Determine if the patient's goals are met and decide whether the plan of care should be discontinued, continued, or revised.
diagnosis
Nurse analyzes, validates, and clusters patient data to identify patient problems. Patient data clusters are stated in standardized language, which provides clarity and universal understanding by all health care providers.
evaluation
Nurse determines if the patient's goals are met, examines the effectiveness of interventions, and decides whether the plan of care should be discontinued, continued, or revised.
assessment
Nurse gathers patient data through observation, interviews, and physical assessment.
implementation
Nurse initiates specific nursing interventions and treatments designed to help the patient achieve established goals and outcomes.
planning
Nurse prioritizes the nursing diagnoses and identifies goals that are realistic, measurable, and patient-focused, with specific outcomes.
Which statement illustrates the collaborative characteristic of the nursing process?
Nurses may incorporate actions by the patient or family to address patient goals.
Which actions demonstrate a nurse utilizing critical thinking when her patient complains of increased pain at the surgical site?
The nurse verifies that no pain medications were ordered and calls provider on call for pain medications. The nurse uses non-pharmaceutical treatment of focused deep breaths to relieve pain for patient. The nurse assesses vital signs and checks to see when patient was last medicated for pain. The nursing process requires nurses to think analytically using many aspects of critical thinking. The nurse must be able to assess patients accurately and then organize and analyze the findings to provide safe care. The nurse is assessing to see if there is new data that necessitates modification of the existing plan of care. The nurse assesses the surgical site to determine the cause of the increased pain. In addition to assessing vital signs and pain level, the nurse should assess the surgical site to determine if there are new signs of poor wound healing or infection. The root cause of the pain should be considered when planning further interventions.
summary
The nursing process is a way of thinking critically when developing and implementing an individualized care plan for a patient. The concept of the nursing process was pioneered by early nurse theorists such as Lydia Hall. The nursing process involves five steps: assessment, diagnosis, planning, implementation, and evaluation. Critical thinking and using the nursing process helps nurses to collect essential data, clearly express the needs of patients, and communicate those needs to the health care team. Realistic goals can then be set and interventions can be customized. The nursing process is dynamic, collaborative, outcome-oriented, organized, analytical, and adaptable. Using the nursing process helps ensure that patients receive effective and safe care in any health care setting. Previous
adaptable
The nursing process is adaptable for hospital inpatient care, outpatient care, long-term care, or care in a home setting. The nursing process can be used to assess the needs of individuals as well as large communities.
dynamic
The nursing process is dynamic; it changes over time in response to patients' individual needs. The dynamic, responsive nature of the nursing process allows it to be used effectively with patients in any health care setting and at every level of care, from the intensive care unit to outpatient wellness clinics.
outcome-oriented
The nursing process is outcome-oriented, so health care team members are held accountable for their actions with regard to patient care. Patients benefit from outcome-oriented care because they are consistently and safely treated. The care plan is effective if the agreed-upon goals are met; otherwise, the plan is modified to better address patient needs.
planning
The provider orders heparin (blood-thinning medication) injection therapy for the blood clot. The patient is also prescribed bed rest, compression stockings, and limited dietary intake of vegetables like spinach, which may reduce the effect of blood-thinning medications. The nurse creates a customized care plan for the patient, which includes modified rest, diet, and exercise. The nurse also plans to teach the patient how to self-inject heparin.
What nursing skill is essential when utilizing the nursing process?
critical thinking
What is a part of the assessment process?
data collection
How are the steps of the nursing process utilized?
diagnose needs and plan goals assess individuals,families, communities identify outcome criteria identify specific nursing interventions
Which characteristic of the nursing process refers to changes over time in response to patients' individual needs?
dynamic
the five steps that make up the nursing process allow it to be
dynamic
A patient reports that his pain level is now 6 out of 10. The patient's goal for a pain level of 3-4 out of 10 is not met. Which step of the nursing process does this statement reflect?
evaluation
which step is part of the nursing process preparing analysis treatment evaluation
evaluation
Ernestine Wiedenbach (1963)
identified four main elements of nursing: philosophy, purpose, practice, and the art of nursing.
nursing process
is the systematic method of critical thinking that helps nurses work in an organized, methodical, and effective manner as they develop individual care plans for patients.
Who first pioneered the term "nursing process?"
lydia hall
by using this process
nurses gather patient data, and assess and communicate patient needs, goals, and interventions with other members of the health care team.
Which method was developed to advance the nursing profession and how nurses provide care to all patients?
nursing process
critical thinking
nursing process
Nurse Lydia Hall
pioneered the usage of the term nursing process in 1955. She presented her theory of nursing by drawing three interlocking circles, each representing a distinct aspect of nursing: care, core, and cure.
A nurse educator is reviewing the steps of the nursing process with the class. While reviewing a case study, the educator asks the students to determine which part of the process a nurse uses when establishing short- and long-term goals with the patient. How should the students respond?
planning
Which term describes the nurse prioritizing the diagnoses and identifying goals that are realistic, measurable, and patient-focused with specific outcomes?
planning
