Nursing Fundamentals: Handout lecture – Nursing process
I.
Introduction
a. The nursing process is a __________________________ method of providing
_____________ to clients
b. Allows nurses to ___________________________________ plans and activities to
i. _____________________
ii. Other _________________ care professionals
iii. _______________________
II.
Overview
a. Process: “A series of ________________ or acts that lead to accomplishment of some
_________________________ or _____________________.”
b. Purpose of to provide client care that is
i. __________________________
ii. __________________________
iii. __________________________
iv. __________________________
c. Consists of _____________# steps
i. _____________________________
ii. _____________________________
iii. _____________________________
iv. _____________________________
v. _____________________________
d. _____________ on each other. Not ___________________
e. Nursing process is _______________________ and requires creativity
f. Used throughout the ______________ span, and in ___________ care setting.
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III.
Small Group Questions
a. How many steps are in the nursing process
b. What are the names of each of the steps
c. What is the purpose of the nursing process
d. In what clinical setting is the nursing process used?
IV.
Assessment
a. Step # __________
b. Involves
i. __________________ data
ii. __________________ data
iii. Organizing ________________
iv. Interpreting the _______________
v. ______________________ the data
c. Purpose: _______________________ collection
d. Types of assessment
i. Comprehensive
1. Base_____________________
2. ___________________ & psychosocial
ii. Focused Assessment
1. ________________ in scope
2. Screening for a _________________ problem
3. ______________ stay
iii. Ongoing assessment
1. Follow - _____________
2. Monitoring and _________________ related to a specific problem
e. Sources of Data
i. Primary source
1. ___________________________________________________
ii. Secondary sources
1. ____________________________________________________
f. Types of data
i. Subjective
1. Data from the ________________ point of view
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2. Main way to collect subjective data? _____________________
ii. Objective data
1. __________________ and measurable
2. Main way to collect objective data? _______________________
V.
Small Group Questions
a. Baby Jane, 2 months old, is seen in the doctors for her initial immunization and well
baby check-up. What type of assessment should the nurse perform?
b. Give an example of a primary source of data
c. Give an example of a secondary source of data
d. Which of the following are objective data and which are subjective data?
i. Nausea
ii. Vomiting
iii. Unsteady gait
iv. Anxiety
v. Bruises on the right arm and face
vi. Temperature of 101 F
VI.
Diagnosis
a. Step # __________________
b. “A clinical _____________________about individual, family or community responses
to actual or potential health problems/ life processes. A nursing diagnosis provides the
basis for selection of nursing ___________________to achieve outcomes for which the
nurse is accountable.”
Medical Diagnosis
Nursing Diagnosis
Identifies conditions the ______________ is
Identifies situations the ________________ is
licensed & qualified to treat
licensed & qualified to treat
Focuses on_____________, injury or disease
Focuses on the clients _______________ to
processes
actual or potential health / life problems
Remains ____________ until a cure is effected
______________ as the clients response and/or
the health problem changes
i.e. Breast cancer
i.e. Knowledge deficit
Powerlessness
Grieving, anticipatory
Body image disturbance
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Individual coping, ineffective
Nursing diagnosis
Medical diagnosis
Breathing patterns, ineffective
Chronic obstructive pulmonary disease
Activity intolerance
Cerebrovascular accident
Pain
Appendectomy
Body image disturbance
Amputation
Body temperature, risk for altered
Strep throat
VII.
Planning
a. Step # ____________
b. Type of planning
i. ___________________ planning
ii. ___________________ planning
iii. ___________________ planning
c. Goals
i. Short term ___________________________________________
ii. Long term: __________________________________________
d. Developing specific nursing interventions
i. Independent nursing interventions; _____________________________
ii. Interdependent nursing interventions: ___________________________
iii. Dependent nursing interventions: ______________________________
e. Prioritizing the nursing process: Maslow’s hierarchy of needs
i. _________________________________
ii. _________________________________
iii. _________________________________
iv. _________________________________
v. _________________________________
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VIII.
Implementation
a. Step #______________
b. Execute!
c. Delegation
IX.
Evaluation
a. Step # _______________________
b. Determine whether the clients _______________________ have been met, partially met
or not met
X.
Small Group Questions
a. What part of the nursing process do each of the items belong?
i. Will participate in some exercise daily
ii. Will lose 2 lbs./month
iii. Weight gain 8 lbs in one week
iv. Schedule return visit with nurse in one week
v. On return visit, the client was found to have lost 1.8 lbs.
vi. Eats in response to boredom
vii. Discuss risk factors and symptoms of diabetes
viii. Conduct a dietary history, using open-ended statements to assist the client in
exploring psychological factors that may contribute to eating
ix. Altered nutrition; more than body requirement
x. Age: 55
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