Nursing process

Interpret & analyze clustered data. Identify client’s problems and strengths

An appraisal whether expected outcomes are met. An appraisal of the effectiveness of nursing care plan

This includes monitoring, teaching, further assessing, reviewing NCP, incorporating physicians orders and monitoring cost effectiveness of interventions

�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: Utilizes critical thinking processes

TRUE

FALSE

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

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

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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