Sherpath Chapter 16: The Five Steps of the Nursing Process

What are the five steps in the correct order? -diagnosis -evaluation -assessment -planning -implementation

(ADPIE!!!) -assesment> diagnosis> Planning> Implemenation> Evalutation

Subjective data:

spoken data (by patient or someone else). -typically documented in direct quotes -describe patient feelings (pain)

Types of data:

subjective and objective

What questions should the nurse ask when evaluating the effectiveness of nursing interventions? --What is the best nursing diagnosis to cover this cluster of signs and symptoms? --What are the signs and symptoms that can be used to diagnose the patient's condition? --Did the patient meet the goals established during the planning phase? --Should the plan of care be discontinued? --Does the care plan need to be modified in response to patient changes?

--Did the patient meet the goals established during the planning phase? --Should the plan of care be discontinued? --Does the care plan need to be modified in response to patient changes?

The Nursing process steps:

-Assessment -Diagnosis -Planning -Implementation -Evaluation

Assessment definition:

-Gather data through observation, interviews, and physical assessment. -the organized and ongoing appraisal of a patient's well-being.

Types of diagnostic labels

-actual:uses 3 parts -risk: uses 2 parts -health promotion: uses 2 parts

What is the fifth step of the nursing process that includes a decision point on whether to discontinue, continue, or revise the plan of care? -assessment -planning -evaluation -implementation

-evaluation ---Evaluation is the fifth step of the nursing process. The 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.

Nursing care can be categorized as direct or indirect, depending on the nursing ___________. -Implementation -Interventions -Staff -Health care team

-interventions ----interventions are either direct or indirect

Diagnostic label: HEALTH-PROMOTION

-nursing diagnostic label - Defining characteristics

all goals should be:

-patient focused, realistic and measurable

Diagnostic Label: RISK

-patients identified need or problem -factors indicating vulnerability

Diagnostic Label: ACTUAL

-patients identified need or problem -etiology or underlying cause -signs and symptoms

What occurs in the Planning step of the nursing process?

-prioritizing various nursing diagnoses -establishes short and long term goals -chooses outcome indicators -identifies interventions to address patient goals

What word does the nurse use to describe the five steps? -race -process -story -content

-process

Care plan: protocols

-protocols are written plans that can be generalized to groups of patients with similar clinical needs that do not require a health care providers order

Information received from the patient's family members, friends, or other nurses is what type of data? (select all that apply) -comprehensive -objective -primary -secondary -subjective

-secondary: Secondary data come from sources other than the patient. -Subjective: Subjective data may come from either the patient or from family members.

In the planning phase nurses need to establish

-short and long term goals (depending on the patients immediate and future needs)

A patient has a painful jaw that clicks during chewing. The nurse developed a care plan and taught the patient how to use a bite guard. What step of the nursing process did the nurse exhibit by teaching use of the bite guard? -Evaluation -Implementation -Assessment -Planning

Implementation ----Implementation includes initiating specific nursing interventions designed to help achieve established goals.

Implementation defintion:

Initiate interventions and treatments to help patients achieve established goals or outcomes.

A nurse is caring for a patient who just had a colostomy. What type of nursing diagnosis (actual, risk, or health-promotion) should the nurse select when developing the plan of care? -Risk, since the patient's identified need is the diagnosis of colostomy. -Risk, since the patient is at risk for infection at the site of the surgical incision. -Actual, since the patient is at risk from factors indicating vulnerability. -Actual, since the patient is in need of health-promotion, given the nursing diagnostic label of colostomy.

Risk, since the patient is at risk for infection at the site of the surgical incision. ----The patient does have a risk factor: a surgical incision due to the colostomy. The nurse would select this nursing diagnosis as a risk diagnosis for this patient.

True or False: At each step of the nursing process, revisions to the plan of care may occur

True

A nurse is caring for a patient with decubitus ulcers who is dehydrated and suffering from malnutrition. In the evaluation stage, what evidence about the decubitus ulcers should initiate the nurse to change the nursing care plan? -new decubitus ulcers have formed -there is no change in decubitus ulcer size -decubitus ulcers are now smaller -color of decubitus ulcers has improved

new decubitus ulcers have formed ----If the current treatment has resulted in development of new decubitus ulcers the current treatment is not working and should be reevaluated.

Primary data:

obtained directly from patient

What does the evaluation phase include? --Judgment about patient's desire to perform interventions. --The patient being discharged from the hospital. --The nurse's implementation of the patient's plan of care. --Patient's achievement of short- and long-term goals.

-Patient's achievement of short- and long-term goals. ---The evaluation phase is specifically when the nurse determines whether the patient's short- and long-term goals were met.

what determines if data is primary or secondary?

Data collection begins at the first direct or indirect encounter with a patient. The data source determines if it is primary or secondary.

A nurse is evaluating the care plan for a pregnant patient. What is the main reason the nurse would ask the patient about support systems and eating habits? -Ensure individualized care. -Concern over the baby arriving prematurely. -Facilitate setting patient outcomes. -Determine if the patient has other children.

Ensure individualized care. ----During evaluation, nurses need to ask questions where answers help determine how best to proceed with individualized care.

Evaluation definition:

Evaluate goals, determine effectiveness of interventions, and decide if plan of care needs to be revised.

True or false: during the evaluation step of the nursing process evaluating whether the patients goals were attained is not a collaborative process that involves the patient

FALSE it should involve the patient; patient is priority

A nurse is caring for a patient with a UTI. The nurse's selection of two nursing diagnoses includes acute pain and impaired urinary function. What evidence would lead the nurse to diagnose acute pain? (select all that apply) -low back aching -burning upon urination -frequency of urination -urgency of urination -incontinence of urination

Low back aching ----Low back aching or acute pain is evidence for the diagnosis of acute pain. Burning upon urination ----Burning upon urination is evidence for the diagnoses of acute pain.

What is Holistic Assessment?

Nurses assess the state of a patient's physical, psychological, emotional, environmental, cultural, and spiritual health to gain a better understanding of his or her overall condition.

QSEN focus with implementation

Nurses should read original research articles and systematic reviews of literature related to their specialties to stay current and implement new evidence into practice.

Indirect Nursing Care

care performed on behalf of patients, such as ordering a special diet or arranging with a social worker to set up home care

Nursing diagnosis results from:

carefully analyzing, validating, and clustering related patient subjective (symptoms) and objective (signs) data.

The evaluation phase loops back to which earlier phases of the nursing process when considering new data? Select all that apply. --Implementation --Assessment --Diagnosis --Planning --Goal setting

--assessment: Assessment data do continue to be added to the patient's record to be considered in the evaluation phase. --diagnosis --planning: Planning is made in the third phase and is somewhat repeated in the evaluation phase when reassessing.

A nurse determines the patient's goal of decreased reflux by sleeping on a pillow wedge was not totally met. How does the plan need to be revised? -Add another pillow wedge at night. -Add a step to avoid eating after 7 p.m. -Increase grapefruit juice taken with meals. -Discontinue the plan.

-Add a step to avoid eating after 7 p.m. ----Revising the plan by adding a step is the right strategy.

Scenario question: Amber starts the nursing process by assessing Mrs. Granning. She takes a health history and notes that Mrs. Granning states that she has a constant, dull ache in her lower back and feels the need to urinate almost constantly. Mrs. Granning states she has never experienced these feelings before. When she is urinating, she feels a painful burning sensation. Amber then takes Mrs. Granning's vital signs which are T 37°C (98.6°F), BP 118/72, P 90 and regular, R 12 and unlabored. A clean-catch urinary specimen shows a bacteria count greater than 105 mL, multiple WBCs, and hematuria. After collecting the assessment data, Amber analyzes the data to determine what nursing diagnoses might be assigned to Mrs. Granning?

-Amber selects two actual nursing diagnoses for Mrs. Granning: (1) Acute Pain related to infection as evidenced by patient's report of low back pain and burning upon urination, and (2) Impaired Urinary Function related to inflammation as evidenced by patient's frequency and urgency of urination.

What type of patient-centered care respects the input of family members and other members of the health care team? -Evidence-based -Collaborative -Communicative -Planned

-Collaborative ---Collaborative care is a crucial component of patient-centered care; bringing together and respecting family members and other health care team members are the hallmarks of collaborative care.

What determines if an assessment is primary or secondary? -Data source -Types of data -Categories of data -Subjectivity of the data

-Data source: The source of the data determines whether the assessment is primary (directly from a patient) or secondary (from other places).

The nursing __________ identifies an actual or potential problem or response to a problem. -Diagnosis -Plan -Assessment -Outcome

-Diagnosis ---A nursing diagnosis is meant to identify an actual or potential problem, or a response to a problem.

Diagnostic Labels

-Diagnosis in the nursing process requires naming patient problems using nursing diagnostic labels. ---established and revised every three years by NANDA -

What is the primary purpose for documenting nursing interventions? -facilitate communication -legal record-keeping -implement policy -proof or performance

-Facilitate communication --Communication is the most important reason why proper documentation is performed. It facilitates communication among all health care members and decreases the potential for errors.

Scenario question: Amber starts the nursing process by assessing Mrs. Granning. She takes a health history and notes that Mrs. Granning states that she has a constant, dull ache in her lower back and feels the need to urinate almost constantly. Mrs. Granning states she has never experienced these feelings before. When she is urinating, she feels a painful burning sensation. Amber then takes Mrs. Granning's vital signs which are T 37°C (98.6°F), BP 118/72, P 90 and regular, R 12 and unlabored. A clean-catch urinary specimen shows a bacteria count greater than 105 mL, multiple WBCs, and hematuria. QUESTION: WHAT SUBJECTIVE DATA DID AMBER COLLECT?

-HEALTH HISTORY & SYMPTOMS REPORTED

A nurse is creating a care plan and wants to put direct care items before indirect care items. Which of these is in the correct order? -Order a low-salt diet for the patient, and then help the patient to ambulate. -Set up home care for the patient, and then give the patient an injection. -Arrange for the schedule of the physical therapist to come, and then apply a medicated transdermal patch. -Help the patient ambulate, and then order occupational therapy to come.

-Help the patient ambulate, and then order occupational therapy to come. ---The direct care item, helping the patient ambulate, does come first in this sequence.

What type of patient assessment takes into account factors such as the patient's physical, psychological, emotional, environmental, cultural, and spiritual health? -universal -general -financial -holistic

-Holistic: A holistic assessment takes into account numerous factors of the patient's health: physical, psychological, emotional, environmental, cultural, and spiritual.

What is the most important aspect of a patient-centered care plan? -Implementing teaching early in the patient's recovery -Matching the patient's goals and relevant current status -Selecting several interventions for each nursing diagnosis -Moving the patient from dependence to independence

-Matching the patient's goals and relevant current status ----Goals must match patients' status and be based on current evidence in order for nurses to develop plans that effectively move patients toward meeting those goals and achieving desired outcomes. This is the most important aspect of patient-centered care plans.

Scenario question: Amber starts the nursing process by assessing Mrs. Granning. She takes a health history and notes that Mrs. Granning states that she has a constant, dull ache in her lower back and feels the need to urinate almost constantly. Mrs. Granning states she has never experienced these feelings before. When she is urinating, she feels a painful burning sensation. Amber then takes Mrs. Granning's vital signs which are T 37°C (98.6°F), BP 118/72, P 90 and regular, R 12 and unlabored. A clean-catch urinary specimen shows a bacteria count greater than 105 mL, multiple WBCs, and hematuria. What vulnerabilities does Mrs. Granning have that might indicate the need for a risk diagnosis?

-Mrs. Granning's use of a diaphragm for birth control may be contributing to her impaired urinary function.

Match the category with its corresponding data source. -Obtained directly from patient -Obtained from other healthcare professionals, medical records, test results -Direct quotes describing patient feelings -Blood pressure reading and weight MATCH: -SUBJECTIVE -OBJECTIVE -SECONDARY -PRIMARY

-PRIMARY -SECONDARY -SUBJECTIVE -OBJECTIVE

Scenario question: Amber starts the nursing process by assessing Mrs. Granning. She takes a health history and notes that Mrs. Granning states that she has a constant, dull ache in her lower back and feels the need to urinate almost constantly. Mrs. Granning states she has never experienced these feelings before. When she is urinating, she feels a painful burning sensation. Amber then takes Mrs. Granning's vital signs which are T 37°C (98.6°F), BP 118/72, P 90 and regular, R 12 and unlabored. A clean-catch urinary specimen shows a bacteria count greater than 105 mL, multiple WBCs, and hematuria. QUESTION: DID AMBER COLLECT PRIMARY OR SECONDARY DATA FROM MRS. GRANNING?

-Primary because the data given was given by the patient.

A nurse is caring for a patient with a UTI. Which of these interventions address the patient's short-term goals? -Teaching hygiene practices to prevent further UTIs. -Educating the patient on the signs and symptoms of UTIs. -Applying a heating pad to the low back or abdomen. -Refraining from sexual intercourse. -Discussing the possibility of using a different type of birth control.

-Refraining from sexual intercourse. ----Refraining from sexual intercourse is a short-term goal. -Applying a heating pad to the low back or abdomen. ----A heating pad applied to the low back or abdomen is a short-term goal.

The nurse establishes the ____ of unlicensed health care team members as a crucial balance between collaboration and overlapping responsibilities. -Scope of practice -Direct intervention -Unique skills -Protocols

-Scope of practice ---Because each team member has a defined scope of practice, better collaboration and, therefore, better patient outcomes are expected.

What types of care plans are used in implementation? Select all that apply. -Standing orders that describe specific actions to be taken by a nurse. -General protocols that apply to patients with similar clinical needs. -Detailed descriptions of possible actions to be taken by the nurse. -Care pathways that combine several areas of health care expertise.

-Standing orders that describe specific actions to be taken by a nurse. -General protocols that apply to patients with similar clinical needs. -Care pathways that combine several areas of health care expertise.

Match type of outcome or goal with its correct definition or example. --Within 1 week, the patient will stand with support to brush teeth. --Within 1 week, the patient will stand with support to brush teeth.Short-term goal Within 3 months, the patient will stand unsupported for 20 minutes. --Classification of patient outcomes evaluating the effects of interventions. --Classification of interventions that nurses perform on behalf of patients. MATCH WITH: --NURSING OUTCOMES CLASSIFICATION --SHORT TERM GOAL --NURSING INTERVENTIONS CLASSIFICATION --LONG TERM GOAL

-Within 1 week the patient will stand with support to brush teeth: short term goal -within 3 months the patient will stand unsupported for 20 minutes -classification of patient outcomes evaluating the effects of interventions: Nursing outcomes classification (NOC) -Classification of interventions that nurses perform on behalf of patients: Nursing Interventions Classification (NIC)

Match the type of nursing diagnoses to the correct example of that diagnosis. -Actual: Objective -Risk -Health-promotion -Actual: Subjective MATCH WITH: -PATIENT VOICES READINESS TO LEARN -PATIENT UNSTEADY WHEN WALKING -"MY HEAD HURTS" -SKIN RED WITH OPEN LESION

-actual:objective> skin red with open lesion -risk> patient unsteady when walking -health-promotion> patient voices readiness to learn -actual:subjective>> "my head hurts"

Direct Nursing Care

-care performed on or with patients, such as giving an injection or helping a patient to ambulate

Care plan: Clinical pathways

-combine healthcare expertise to provide better quality care -indirect, direct, independent and dependent interventions are apart of this

Care plan: standing orders

-signed instructions of a health care provider that describe specific actions to be taken by a nurse when access to a provider is not possible or when care is common to a certain type of situation. ---EX: nurses can give flu shots when a patient presents a need for it

When planning patient care what should the nurse prioritize?

-the nursing diagnoses and identifying goals with specific outcome identification

Scenario question: Amber starts the nursing process by assessing Mrs. Granning. She takes a health history and notes that Mrs. Granning states that she has a constant, dull ache in her lower back and feels the need to urinate almost constantly. Mrs. Granning states she has never experienced these feelings before. When she is urinating, she feels a painful burning sensation. Amber then takes Mrs. Granning's vital signs which are T 37°C (98.6°F), BP 118/72, P 90 and regular, R 12 and unlabored. A clean-catch urinary specimen shows a bacteria count greater than 105 mL, multiple WBCs, and hematuria. QUESTION: WHAT OBJECTIVE DATA DID AMBER COLLECT?

-the vital signs and the laboratory results from the clean-catch urine specimen

Why are the five steps in place?(Select all that apply.) -Enable organization of patient care -Ensure comprehensive patient care -Prevent overlap between the steps -Facilitate evaluation of patient care -Promote interdependency between steps

-to ensure that patient care is organized and comprehensive. --they are interdependent (ensures comprehensive care) -facilitate evaluation of patient care

QSEN FOCUS!!!!

Although NANDA-I no longer identifies specific collaborative nursing diagnostic labels, it is essential that nurses work with various members of the interdisciplinary health care team to plan holistic patient care. Respecting the unique skills and contributions of others on the health care team facilitates better communication and achievement of patient health goals.

Diagnosis definition:

Analyze, validate, and cluster data to identify patient problems. Select and identify nursing diagnoses.

A nurse is caring for a patient who is cyanotic and has edema. The nurse is making a list of the patient's physical, psychological, emotional, environmental, cultural, and spiritual health. What stage of the nursing process is this? -assessment -diagnosis -planning -evaluation

Assessment ----The correct step in the nursing process is assessment, since the parts of holistic assessment are being considered.

A nurse is admitting a new patient who has heart failure and pitting edema. At each step of the nursing process, what is likely to happen? -The plan of care follows directly from the diagnosis. -Revisions will be avoided until after the evaluation phase of the care plan. -Information from other steps will be used to complete the plan of care. -The patient will improve during each step of the nursing process.

Information from other steps will be used to complete the plan of care. ----The steps are interdependent, and information from other steps will be used to complete and implement an effective plan of care.

Planning definition:

Prioritize nursing diagnoses and set realistic, measurable, patient-focused short- and long-term goals or outcomes.

A nurse is ready to set goals for a patient who is recovering from a hip replacement. The nurse sets goals for the first three days and for the first three weeks. What part of the nursing process is this? -planning -assessment -diagnosis -evaluation

Planning ----Planning includes prioritizing nursing diagnoses and setting patient-focused short- and long-term goals.

The nurse is receiving a report on a patient recovering from a myocardial infarction with low oxygen saturation. With a nursing diagnosis of low blood oxygen, what other interdisciplinary professionals may be consulted for collaboration of this patient? -Respiratory therapist, cardiologist, and nephrologist -Cardiologist, urologist, and pulmonologist -Rheumatologist, respiratory therapist, and cardiologist -Respiratory therapist, cardiologist, and pulmonologist

Respiratory therapist, cardiologist, and pulmonologist ----A respiratory therapist, a cardiologist, and a pulmonologist are all likely members of a health care team concerning a diagnosis of low blood oxygen.

Why must nursing diagnoses include up-to-date diagnostic labels as determined by NANDA International? -Patient care depends on knowledge of holistic categories. -Accurate clustering of symptoms requires use of NANDA diagnostic labels. -Standardized language facilitates care recognized by all health care team members. -NANDA diagnostic label usage results in more efficient workflow and organization. NOT SURE

Standardized language facilitates care recognized by all health care team members. ---When health care team members agree on common, standardized terms for diagnoses, patient care is improved

A nurse is caring for a 10-year-old tracheotomy patient admitted the previous night. When assessing the patient's pain level, is the nurse assessing subjective or objective data? -Subjective data, because only the patient can experience the pain. -Subjective data, because the blood pressure is an accurate measure of the patient's pain. -Objective data, because the pain level can be turned into a number on a one to ten scale. -Objective data, because the patient can point to the "oucher" picture indicating the experienced pain level.

Subjective data, because only the patient can experience the pain. ----The pain level is subjective, because it is spoken or pointed out as an "oucher" card in the case of the patient with a tracheotomy.

When a patient reports feeling anxious, what is the subjective data called? -Cluster of symptoms -Diagnosis -Sign -Symptom

Symptom ---It can be helpful to remember that symptoms, such as anxiety, may lead a patient to know something is wrong, but signs are objective and taken by the health care professionals NOT A SIGN BECAUSE A SIGN IS TAKEN OBJECTIVELY.

What is the nursing process?

The nursing process is the method by which professional nurses systematically identify and address actual or potential patient problems.

A patient with diabetes reports to the clinic for diabetes education. The nurse learns that the patient's wife prepares the family meals. Why is it important to include the patient's wife in the teaching? -She can report when he is not adhering to the care plan. -The wife can learn how to follow his new diet too. -The main person responsible for managing the patient's diabetes may be the wife. -Including a second person in teaching is protocol for the facility.

The wife can learn how to follow his new diet too. ----The nurse works with family members to develop patient-centered care plans.

A nurse is caring for a patient at risk for appendicitis. When considering the assessment, why should the nurse use the five-step nursing process? -To set up the correct surgery time for the health care provider -To carefully match what is done in other hospitals -To systematically identify actual or potential patient problems -To better console families who are anxious about their loved one

To systematically identify actual or potential patient problems ----The nursing process is the method by which professional nurses systematically identify and address actual or potential patient problems.

Secondary data:

collected from family members, friends, other healthcare professionals, and written sources (medial records & tests)

Objective data:

observable information gathered on the basis of what can be seen, measured, tested --EX:data collected from medical records, test results, or physical assessment