The Nursing Process (Assessment, Nursing Diagnosis, Planning, Implementing, and Evaluating)

What are the 5 steps of the nursing process in order?

1. Assessment.
2. Nursing Diagnosis.
3. Planning.
4. Implementing.
5. Evaluating.

During the Assessment process, you ___________ from primary source (the patient) and secondary
source (family, etc.)
collect data

During the Assessment process, you have to (1)_______, (2)_________, and (3)_________ the data
you have collected.
1. Interpret.
2. Validate.
3. Analyze.

During the Assessment process, you have to apply (1)_______________, personal knowledge, clinical
experiences, and (2)__________________.
1. Critical thinking.
2. Standards of practice.

During the Assessment process, you will establish a database for the patient of perceived
(1)__________, (2)__________, and (3)___________.
1. needs.
2. health problems.
3. responses.

What can guide you through your initial assessment and screening?
Cues and Inferences

What are 2 comprehensive assessment approaches?

1. Gordon's Functional Health Patterns.
2. Problem Oriented Approach.

What are the two types of data that you can collect?
Subjective and Objective

What is subjective data?

Usually provided by the patient.
Patient's verbal description of personal health problems.
Feelings, perceptions, and expressions of the patient.
What is objective data?
Is measurable and based on an accepted standard. Ex. centimeters on a measuring tape)
Is measurements or observations of the patient's health problems.
Is collected by family, health care team, medical records.

When conducting a patient centered interview, what kind of question allows the patient to tell in
their own words their health care concerns?
Open ended questions.

What kind of questions are "yes" or "no" type questions, and used to acquire specific information?
Closed ended questions.

Documentation of nursing health history is __________. (6)

1. Timely.
2. Accurate.
3. Thorough.
4. Required for patient record keeping.
5. Considered not done if not documented.
6. A legal and professional responsibility.

What techniques does the physical examination involve? (4)

1. Inspection.
2. Palpation.
3. Percussion.
4. Auscultation.

A ______________ is a set of signs or symptoms gathered during assessment that you group together
in a logical way.
data cluster

What are "defining characteristics"?

symptoms, subjective and objective data.

What are some examples of Defining Characteristics?

Pain level of 7 on scale of 1-10.
Crying.
Sweating.
Heart Rate 66 and regular.
"I hate to eat anything green".
"Sometimes I bleed when I have a bowel movement".
Black, tarry stools

What are the 3 types of nursing diagnosis?

1. Actual Nursing Diagnosis.
2. Risk Nursing Diagnosis.
3. "Health Promotion Nursing Diagnosis.
What is an "Actual Nursing Diagnosis"?
Describes human responses to health conditions or life processes.

What is a "Risk Nursing Diagnosis"?

Describes human responses to health conditions/life processes that may develop

What is a "Health Promotion Nursing Diagnosis"?

A clinical judgment of motivation, desire, and readiness to enhance well-being and actualize human
health potential

How do you write a nursing diagnosis?

Start with the "nursing diagnosis" followed by "Related to" ______ followed by "As evidenced by"
________.
Example:Acute Pain "related to" muscle tenderness "as evidenced by" pain level of 8 on scale of 1-
10 of right calf area.