The Nursing Process
This set was designed to be listened to using the "play" setting on the phone ap. Please
excuse the periods between abbreviations.
Part 1 Resource: Class and power points
Nurses use this process to help them care for patients each day. - -Nursing Process
What are the major steps of the nursing process? - -Assess, diagnose, plan,
intervene, evaluate
What questions may help you to assess a situation? - -Open ended
This is the first step in the nursing process. Data is gathered. Data sources may be
extensive. (A, D, P, I, or E?) - -Assessment
Where does data come from to complete nurse assessment? - -Health History (PMH
and PSH). General observations about patient or client. Review of Systems (ROS) is
subjective. Physical Assessment is objective. Diagnostic Studies (US, CXR, and the like)
What is the principle of sorting data? - -Cluster data into groups of defining
characteristics that will compose a nursing diagnosis.
when creating a nursing diagnosis pertaining to pain, which data pieces would be
included? pacing. slow heart rate. grimacing. touching area of pain - -Slow heart rate
is not a sign or symptom of pain.
1
Page
, Give some examples of high priority nursing diagnoses. - -Risk for aspiration,
ineffective airway clearance, latex allergy response, decreased cardiac output
Give some examples of high priority nursing diagnoses - -risk for infection, acute pain
Give some examples of low priority nursing diagnoses - -incontinence, constipation,
ineffective coping
What concepts would the nurse consider when prioritizing nursing diagnoses? - -
ABC's, CAB's, Maslow's Hierarchy, and patient-specific problems. For example, in a
syncope patient prevention of constipation may become a higher priority.
The nurse creates a patient outcome stated as follows: Patient will use a self-report pain
tool to identify current pain level and establish a comfort-function goal. What is missing
from this ? - -Time needs to be considered. Smart goals are specific, measurable,
attainable (or action-focused), realistic, and time-oriented.
The nurse creates a patient outcome stated as follows: Throughout my shift, the client will
demonstrate effective coughing technique. What is missing? - -It's not measurable or
specific. A better goal will explain how, how often, or for how long the patient performs the
task.
When planning action goals, the nurse keeps in mind that which individual is responsible
for performing these actions? - -Patient - use smart goals to define actions.
Which individual is responsible for implementation of a nursing care plan? - -The
nurse
2
Page
This set was designed to be listened to using the "play" setting on the phone ap. Please
excuse the periods between abbreviations.
Part 1 Resource: Class and power points
Nurses use this process to help them care for patients each day. - -Nursing Process
What are the major steps of the nursing process? - -Assess, diagnose, plan,
intervene, evaluate
What questions may help you to assess a situation? - -Open ended
This is the first step in the nursing process. Data is gathered. Data sources may be
extensive. (A, D, P, I, or E?) - -Assessment
Where does data come from to complete nurse assessment? - -Health History (PMH
and PSH). General observations about patient or client. Review of Systems (ROS) is
subjective. Physical Assessment is objective. Diagnostic Studies (US, CXR, and the like)
What is the principle of sorting data? - -Cluster data into groups of defining
characteristics that will compose a nursing diagnosis.
when creating a nursing diagnosis pertaining to pain, which data pieces would be
included? pacing. slow heart rate. grimacing. touching area of pain - -Slow heart rate
is not a sign or symptom of pain.
1
Page
, Give some examples of high priority nursing diagnoses. - -Risk for aspiration,
ineffective airway clearance, latex allergy response, decreased cardiac output
Give some examples of high priority nursing diagnoses - -risk for infection, acute pain
Give some examples of low priority nursing diagnoses - -incontinence, constipation,
ineffective coping
What concepts would the nurse consider when prioritizing nursing diagnoses? - -
ABC's, CAB's, Maslow's Hierarchy, and patient-specific problems. For example, in a
syncope patient prevention of constipation may become a higher priority.
The nurse creates a patient outcome stated as follows: Patient will use a self-report pain
tool to identify current pain level and establish a comfort-function goal. What is missing
from this ? - -Time needs to be considered. Smart goals are specific, measurable,
attainable (or action-focused), realistic, and time-oriented.
The nurse creates a patient outcome stated as follows: Throughout my shift, the client will
demonstrate effective coughing technique. What is missing? - -It's not measurable or
specific. A better goal will explain how, how often, or for how long the patient performs the
task.
When planning action goals, the nurse keeps in mind that which individual is responsible
for performing these actions? - -Patient - use smart goals to define actions.
Which individual is responsible for implementation of a nursing care plan? - -The
nurse
2
Page
