Fundamentals

• Nursing Process

  A systematic, rational method of planning and providing individualized nursing care. Refers to a series of phases describing the practice of nursing.
• Ida Jean Orlando


  • Theorist who developed the nursing process in her theory about the Dynamic Nurse-Patient Relationship (1958) which focuses on the interaction between the nurse and patient, perception validation, and the use of the nursing process to produce outcomes or patient improvement.
• Lydia Hall


  • First used/mentioned/introduced the term NURSING PROCESS.
• Critical Thinking


  The process of intentional higher level thinking to define a client's problem, examine the evidence-based practice in caring for the client, and make choices in the delivery of care.
• Critical Reasoning


  The cognitive process that uses thinking strategies to gather and analyze client information, evaluate the relevance of the information, and decide on possible nursing actions to improve the client's physiologic and psychosocial outcomes.
• Inductive Reasoning

  • Generalizations are formed from a set of facts or observations. When viewed together, certain bits of information suggest a particular interpretation. Inductive reasoning moves from specific examples (premises) to a generalized conclusion.
• Deductive Reasoning


  • Reasoning from general premise to the specific conclusion.
• Inductive Reasoning


  • A nurse who observes a client who has dry skin, poor turgor, sunken eyes, and dark amber urine and who is determined to be dehydrated (premise) concludes that the presence of those signs in other clients indicates that they are dehydrated.
• Deductive Reasoning


  • Upon assessing a patient with shortness of breath and a history of heart failure, the nurse recalls that fluid overload can contribute to respiratory distress. The nurse then considers administering a diuretic to alleviate the symptoms.
• If a patient with a history of asthma presents with shortness of breath, we can deduce that the patient's current condition is related to their asthma.
• If a patient with a history of diabetes has high blood sugar levels, we can deduce that there is a relationship between diabetes and blood sugar levels.
• If patients who consistently engage in deep breathing exercises show improved oxygen saturation levels, we can inductively conclude that deep breathing exercises have potential benefits.
• If patients consistently report reduced pain levels after administering a new pain medication, we can inductively conclude that the new pain medication is potentially effective.
• Fact


  A statement that can be proven true or false.
• Inference


  A conclusion drawn based on available information.
• Opinion


  A personal view or judgment that is not necessarily based on facts.
• Judgment


  An evaluation or assessment of a situation or person.
• The statement "Patient has a temperature of 101°F" is a fact.
• The statement "I believe the patient is non-compliant with medication" is an opinion.
• Assessment


  Systematic and continuous collection, organization, validation, and documentation of data.
• Data Collection


  The process of gathering information about a client's health status. Data collection must be both systematic and continuous to prevent the omission of significant data and reflect a client's changing health status.
• Database


  Contains all the information about a client; it includes the nursing health history, physical assessment, primary care provider's history and physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel.
• Models and Frameworks

  • Wellness Models
  • Body System Model
  • Maslow's Hierarchy of Needs
  • Developmental Theories (Havighurst's age periods and developmental tasks, Freud's five stages of development, Erikson's eight stages of development, Piaget's phases of cognitive development, Kohlberg's stages of moral development)
• Nursing Diagnosis


  A clinical judgement about individual, family, or community responses to actual and potential health problems or life processes that the nurse is licensed and competent to treat.
• Medical Diagnosis


  The identification of a disease condition based on a specific evaluation of physical signs, symptoms, the patient's medical history and the results of diagnostic tests and procedures.
• Types of Nursing Diagnoses


  • Problem-based Dx
  • Health Promotion Dx
  • Risk Nursing Dx
  • Syndrome Dx
• Problem-based Dx


  A client problem that is present at the time of the nursing assessment, based on the presence of associated signs and symptoms.
• Health Promotion Dx


  Relates to clients' preparedness to implement behaviors to improve their health condition. Begins with "Readiness for Enhanced..."
• Risk Nursing Dx


  A clinical judgement that a problem does not exist but the presence of risk factors indicates that a problem is likely to develop unless the nurse intervenes.
• Syndrome Dx


  A cluster of nursing diagnoses that have similar interventions.
• Nursing Diagnoses


  Relate primarily to the nurse's independent functions, that is, the areas of healthcare that are unique to nursing and separate and distinct from medical management.
• Nursing Diagnosis Components

  Problem (P): statement of the client's response (nursing diagnosis label), Etiology (E): factors contributing to or probable causes of the response, Signs and symptoms (S): defining characteristics manifested by the client.
• Nursing Diagnosis Practice Drills

  • Scenario 1: Actual Nursing Diagnosis - Ineffective Therapeutic Regimen Management related to missed insulin doses.

  Scenario 2: Risk Nursing Diagnosis - Risk for Falls related to impaired balance and unsteady gait.

  Scenario 3: Health Promotion Nursing Diagnosis - Readiness for Enhanced Cardiovascular Health related to regular physical exercise and low-sodium diet.

  Scenario 4: Actual Nursing Diagnosis - Impaired Gas Exchange related to airflow limitation and increased respiratory effort.

  Scenario 5: Risk Nursing Diagnosis - Risk for Impaired Skin Integrity related to prolonged bedridden status, limited mobility, and exposure to moisture from perspiration.
• Planning


  Deliberative, systematic phase of the nursing process that involves decision making and problem solving.
• Nursing Intervention


  Any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.
• Client Care Plan

  The end product of the planning phase.
• Types of Planning

  • Initial Planning
  • Ongoing Planning
  • Discharge Planning
• Initial Planning


  Involves the development of a preliminary plan of care by the nurse who performs the admission assessment.
• Ongoing Planning


  All nurses who work with the client do ongoing planning. As nurses obtain new information and evaluate the client's responses to care, they can individualize the initial care plan further.
• Discharge Planning


  The process of anticipating and planning for needs after discharge. A crucial part of a comprehensive health care plan and should be addressed in each client's care plan.