NCM 101 A Quiz 1

• In 1958, Ida Jean Orlando started the nursing process that still guides nursing

  care today.
• THE NURSING PROCESS

  Defined as a systematic approach to care using the fundamental

  principles of critical thinking, client-centered approaches to treatment,

  goal-oriented tasks, evidence-based practice (EDP) recommendations,

  and nursing intuition.
• THE NURSING PROCESS

  • Organized and Systematic

  • Goal-Oriented

  • Humanistic Care
• CHARACTERISTICS OF THE NURSING PROCESS

  • Cyclic and dynamic nature

  • Client centeredness

  • Focus on problem-solving and decision-making

  • Goal oriented

  • Interpersonal and collaborative style

  • Universal applicability

  • Use of critical thinking
• 5 STAGES OF THE NURSING PROCESS

  • ASSESSMENT
  • DIAGNOSIS
  • PLANNING
  • IMPLEMENTATION
  • EVALUATION
• ASSESSING

  A systematic, dynamic way to collect and analyze data about a client, the

  first step in delivering nursing care.
• The primary source of collecting data is the client
• Secondary Source – relatives, healthcare team members, laboratory

  report and diagnostic tests.
• Subjective -from the client (symptom)
• Objective - observable data (sign)
• Such examples of data collection methods are nursing interviews (history) and health assessments (system reviews)
• The 4 types of physical exams/assessments are inspection, palpation, percussion, and auscultation.
• ORGANIZING DATA

  Clustering data according to a nursing model helps to identify nursing

  diagnoses and problems.
• Concepts that can help organize the data are:

   Henderson’s Components of Nursing Care

   Gordon’s Functional Health Patterns

   NANDA’s Human Response Patterns

   Maslow’s Theories
• VALIDATING DATA

  The act of “double-checking” or verifying data to confirm that it is accurate

  and complete.
• VALIDATING DATA Helps avoid:

   Making assumptions

   Missing pertinent information

   Misunderstanding situations

   Jumping to conclusions or focusing in the wrong direction

   Making errors in problem identification
• DOCUMENTING DATA

  Establish a database about the client’s response to health concerns

  or illness
• DIAGNOSING

  The nurse’s clinical judgment about the client’s response to actual or potential

  health conditions or needs
• PLANNING

  Based on the assessment and diagnosis, the nurse sets measurable and

  achievable short- and long-range goals for this patient
• IMPLEMENTING

  Carrying out (or delegating) and documenting planned nursing interventions
• Goals of Implementing

  o Assist the client to meet desired goals/outcomes

  o Promote wellness

  o Prevent illness and disease

  o Restore health

  o Facilitate coping with altered functioning

  o Categories of Implementation /Interventions
• Categories of Implementation /Interventions

   Independent Actions

   Dependent Actions

   Interdependent/Collaborative Actions
• EVALUATING

  Measuring the degree to which goals/outcomes have been achieved
• Components of the Evaluation Process:

  o Collecting data related to the desired outcomes

  o Comparing the data with outcomes

  o Relating nursing activities to outcomes

  o Drawing conclusions about problem status

  o Continuing, modifying, or terminating the nursing care plan
• Interview

  A planned communication or a conversation with a purpose
• Directive Approach to Interviewing

  o Nurse establishes purpose

  o Nurse controls the interview

  o Used to gather and give information when time is limited, e.g., in an

  emergency
• Nondirective Approach to Interviewing

  o Rapport-building

  o Client controls the purpose, subject matter, and pacing

  o Combination of directive and nondirective approaches usually appropriate

  during the information-gathering interview
• Types of Interview Questions

  o Neutral Questions

  o Leading Questions

  o Open Ended Questions

  o Close Ended Questions
• Closed Question

   Restrictive

   Answerable by Yes/No

   Factual

   Less effort and information from client

   “What medications did you take?”

   “Are you having pain now?”
• Open-ended Question

   Specify broad topic to discuss

   Invite longer answers

   Get more information from client

   Useful to change topics and elicit attitudes

   “How have you been feeling lately?”
• The Interview Setting

  o Time and Place

  o Seating arrangements

  o Distance

  o Language
• Stages of an Interview

  • The opening
  • The body
  • The closing