Nursing process
Interpret & analyze clustered data. Identify client’s problems and strengths
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Gather Information/Collect Data from primary/secondary source
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Nurse and client formulate goals to help the client with their problems
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
This is when the nurse organizes a nursing care plan based on the nursing diagnoses.
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Carrying out nursing interventions (orders) selected during the planning step
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
An appraisal whether expected outcomes are met. An appraisal of the effectiveness of nursing care plan
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions
Assessment
Nursing Diagnosis
Planning
Implementing
Evaluating
Diagnose and treat human responses to actual or potential health problems”
Nursing process
Nursing diagnosis
Nursing care plan
A framework for critical thinking
Nursing process
Nursing diagnosis
Nursing care plan
Nursing process: Organized framework to guide practice
TRUE
FALSE
Nursing process: Problem solving method
TRUE
FALSE
Nursing process: Systematic
TRUE
FALSE
Nursing process: Dynamic-always changing, flexible
TRUE
FALSE
Nursing process: Utilizes critical thinking processes
TRUE
FALSE
Nursing process: Universally applicable
TRUE
FALSE
Nursing Diagnosis
1st step
2nd step
3rd step
4th step
5th step
Planning
1st step
2nd step
3rd step
4th step
5th step
Evaluation
1st step
2nd step
3rd step
4th step
5th step
Assessment
1st step
2nd step
3rd step
4th step
5th step
Intervention
1st step
2nd step
3rd step
4th step
5th step
Client
Primary source
Secondary source
Nursing history
Primary source
Secondary source
Family
Primary source
Secondary source
Physical exam
Primary source
Secondary source
From the client (symptom)
Subjective
Objective
Blood Pressure 130/80
Subjective
Objective
Observable data (sign)
Subjective
Objective
I have a headache"
Subjective
Objective
What are the IPPA in assessment for physical exam
Inspection, percussion, palpation, action
Inspectio, palpation, percussion, autistication
Inspection, palpation, percussion, Auscultation
Within the scope of nursing practice
Nursing diagnosis
Medical diagnosis
Focuses on curing pathology
Nursing diagnosis
Medical diagnosis
Stays the same as long as the disease is present
Nursing diagnosis
Medical diagnosis
Identify responses to health and illness
Nursing diagnosis
Medical diagnosis
Can change from day to day
Nursing diagnosis
Medical diagnosis
Within the scope of medical practice
Nursing diagnosis
Medical diagnosis
Formulating a Nursing Diagnosis composes of PED, what is PED
Personal data, email, diagnosis
Problem statement, Ethiology, Diagnosis
Problem statement, Etiology, Signs and symptoms
Problem statement, Etiology, defining characteristic
The client’s response to a problem
Problem statement
Etiology
Defining Characteristics/ Signs and symptoms
What’s the evidence of the problem
Problem statement
Etiology
Defining Characteristics/ Signs and symptoms
What’s causing/contributing to the client’s problem
Problem statement
Etiology
Defining Characteristics/ Signs and symptoms
Prioritize list of client’s nursing diagnoses using
Snellen Chart
Acuity test
Trendelenburg test
Maslow Hierarchy of needs
3 types of Intervention: any action the nurse can initiate without direct supervision
Independent ( Nurse initiated )
Dependent ( Physician initiated )
Collaborative
3 types of Intervention: nursing actions performed jointly with other health care team members
Independent ( Nurse initiated )
Dependent ( Physician initiated )
Collaborative
3 types of Intervention: nursing actions requiring MD orders
Independent ( Nurse initiated )
Dependent ( Physician initiated )
Collaborative
The Key Components in Intervention is MTAP; what's the abbvre of it?
Monitor, teach, administer, perform
Making, tapping, auscultation, percussion
Mentor, touch, Appic, Perform
A critical thinking process for choosing the best actions to meet a desired goal.
Critical Thinking
Problem solving
Decision making
A process that involves clarifying the nature of the problem and suggesting possible solutions.
Critical Thinking
Problem solving
Decision making
A discipline specific, reflective reasoning process that guides a nurse in generating, implementing, and evaluating approaches FUNDAMENTALS OF NURSING PRACTICE LECTURE: 1ST YEAR SUMMER MIDTERM Aki & Kaye 5 of 34 for dealing with client care and professional concerns
Critical Thinking
Problem solving
Decision making
This is performed within the specify time after admission to establish complete database for problem identification.
Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-Lapsed or Ongoing Assessment
Takes place in life-threatening situations in which preservation of life is the top priority.
Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-Lapsed or Ongoing Assessment
Takes place after the initial assessment to evaluate any changes in the client’s functional health. Follow up check up
Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-Lapsed or Ongoing Assessment
To determine status of a specific problem identified in an earlier assessment.
Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-Lapsed or Ongoing Assessment
“head to toe approach” This is an
examination of the client that follows the head-neck-
thorax-abdomen-extremities-toes sequence of
thorax-abdomen-extremities-toes sequence of
assessment.
Cephalocaudal
Body System
Screening examination
This type of examination focuses on the structures and functions of a specific body system: respiratory system, circulatory system, nervous system,
Cephalocaudal
Body System
Screening examination
review of systems” This manner of examination gives emphasis on the client’s chief complaint and its associated signs. This is also a brief review of essential functioning
Cephalocaudal
Body System
Screening examination
Problem does not exist, but the presence of risk factors indicates that a problem is less likely to develop.
Risk nursing Diagnosis
Actual Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Diagnosis
Evidence about the health problem is incomplete or unclear.
Risk nursing Diagnosis
Actual Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Diagnosis
Client problems that are present at the time of the nursing assessment.
Risk nursing Diagnosis
Actual Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Diagnosis
Two or more problem
Risk nursing Diagnosis
Actual Nursing Diagnosis
Possible Nursing Diagnosis
Syndrome Diagnosis
It answers initial assessment. Initial comprehensive plan of care
Initial Planning
Ongoing Planning
Discharge Planning
Before patient go home
Initial Planning
Ongoing Planning
Discharge Planning
Confinement (day to day/shift planning). Done by all nurses who work with the client, occurs at the beginning of the shift as the nurse plans the care to be given that day.
Initial Planning
Ongoing Planning
Discharge Planning
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