Nursing fundamentals: the nursing process ATI Questions and Correct Answers

what is the nursing process? - a cyclical, critical thinking process. it is dynamic, continuous, client-centered, problem-solving, and decision making framework that is foundational to the nursing practice. five steps of the nursing process - 1. assessment/data collection 2. analysis 3. planning 4. implementation 5. evaluation methods of data collection - 1. observation 2. interviews 3. medical history 4. comprehensive or focused physical exam 5. diagnostic and laboratory reports 6. collaboration what is involved in collecting data effectively? - 1. ask appropriate questions 2. listen carefully to responses 3. develop good head to toe assessment skills 4. employ critical thinking and clinical judgment 5. recognize the need to collect data prior to interventions when do you collect subjective data (symptoms)? - during the nursing history what does subjective data include? - 1. symptoms 2. patients feelings 3. patients perceptions 4. description of health status when is objective data (signs) obtained? - during the physical assessment how do nurses obtain objective data? - "nurses feel, see, hear, and smell objective data through observation or physical assessment of the client" primary sources of data - this is what the patients tells the nurse (subjective) or what the nurse observes. secondary sources of data - what others tell the nurse based on what the client has told them (subjective; "she told me that her shoulder is sore every morning") and the objective data is obtained from another source such as, family, friends, health care professional, or records. what three things does the nurse do during assessment? - 1. validate 2. interpret 3. cluster data analysis - use of critical thinking to identify health status or problems, interpret, or monitor the collected data base, reach an appropriate nursing judgment about health status and coping mechanisms, and provide direction for nursing care. what does analysis requires the nurse to do ..? - 1. recognize patterns or trends 2. compare the data with expected standards or reference pages 3. arrive at conclusions to guid nursing care documentation - documentation is essential. it should focus on facts and should be very descriptive. what does planning involve? - 1. establish priorities and outcomes that can be measured and evaluated 2. these priorities and outcomes are what directs selection of interventions 3. three types of planning 4. develop plan of care based on assessment 5. planning is continuous; obtain new info and evaluate responses to care; modify plan of care if necessary 6. discharge planning 7. nurses select priorities, determine outcomes, and select interventions implementation - Nurses base the care they provide on the assessment data, analysis, and the plan of care they developed in the previous steps. what does implementation involve? - 1. problem solving 2. clinical judgment 3. critical thinking to select and implement appropriate interventions 4. use nursing knowledge, priorities of care, and planned outcomes to promote, maintain and restore health. 5. use interpersonal skills and technical skills therapeutic interventions - 1. includes measures nurses take to minimize risk and to respond to unplanned events, such as observation of unsafe practice, a change in a status, or the emergence of a life threatening situation. roles of nurse during implementation - 1. perform nursing actions 2. delegate tasks 3. supervise other health staff 4. document the care and the patients responses. evaluation - 1. nurses evaluate the patients response to the interventions and form a clinical judgment about the extent to which the patient has met the goals/outcomes that were set what does the evaluation determine? - whether or not to modify the plan of care questions to consider-evaluation - 1. " did the client meet the planned outcomes?" 2. "were the nursing interventions appropriate and effective?" 3. "should i modify the outcomes or interventions?" factors that can lead to a lack of goal achievement - 1. incomplete database 2. unrealistic client outcomes 3. nonspecific nursing interventions 4. inadequate time for the client to achieve the outcomes.