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Rasmussen College: NUR 2115 summer Fundamentals of nursing exam 2 study guide,100% CORRECT

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NUR 2115

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NUR 2115

Rasmussen College: NUR 2115 summer Fundamentals of nursing exam 2 study guide Module 4 – clinical judgement and nursing process The nursing process - is a systematic method that directs the nurse and patient, as together they accomplish the following: (1) assess the patient to determine the ...

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Rasmussen College: NUR 2115 summer Fundamentals of nursing
exam 2 study guide

Module 4 – clinical judgement and nursing process
❖ The nursing process - is a systematic method that directs the nurse and
patient, as together they accomplish the following: (1) assess the patient to
determine the need for nursing care,
(2) determine nursing diagnoses for actual and potential health problems, (3)
identify
expected out- comes and plan care, (4) implement the care, and (5) evaluate
the results.

•Systematically collect patient data (assessing) • Clearly identify patient
strengths and actual and potential problems (diagnosing) • Develop a holistic
plan of individualized care that specifies the desired patient goals and related
outcomes and the nursing interventions most likely to assist the patient to
meet those expected outcomes (planning) • Execute the plan of care
(implementing).

An example of the nursing process in action:
Assessing
You are checking on a patient who had abdominal surgery yesterday and hear that
the patient hasconsiderable pain: “It kept me up all night.” The patient has been
reluctant to ask for any pain medication, fearing effects of the drug. “I don’t want
to become a junkie.” The patient’s blood pressure and pulse rate are slightly
elevated.
Diagnosing
You analyze the data just described and write the nursing diagnosis: Unrelieved
pain related to a fear of taking pain-relieving medications. The patient agrees that
this is becoming a problem.
Outcome Identification and Planning
You decide to work with the patient to achieve the outcome: By 3:00 pm, patient
reports sufficient relief of pain to enable him to rest and to get out of bed to go
to the bathroom. The patient wants to accomplish the outcome. You identify
teaching as the primary nursing intervention.

,Implementing
After asking the patient about his experiences with pain- relieving medications,
you explain thatalthough many of these drugs are addictive when abused, there
is no harm if they are taken as prescribed postoperatively. You also explain that
it is important for him to experience enough pain relief to be able to cough and
deep breath, ambulate, and do other things important to his recovery. You
suggest that the medication will be most effective if taken before his pain peaks

,and becomes intense. You administer the prescribed medication for pain when
the patient indicates that he is willing to give it a try.

Evaluating
After enough time has elapsed for the medication to take effect, you check back
with the patient to evaluate whether he has obtained relief and met his outcome.
If the patient is satisfied and you both feel that comfort is no longer a problem,
you terminate the plan of care for this diagnosis. If the patient still feels pain or is
dissatisfied with the medication, each of the preceding steps of the nursing
process is re-evaluated, and necessary changes are made in the plan of care.

Nursing process continues…
Assessing is the systematic and continuous collection, analysis, validation, and
communication of patient data, or information.
Assessing - Preparing for data collection • Collecting data • Indentifying cues
and making inferences • Validating data • Clustering related data and
indentifying patterns • Reporting andrecording data
Types of assessments
Nursing assessments include:
▪ comprehensive initial assessment
▪ focused assessment
▪ emergency assessment
▪ time-lapsed assessment
Initial assessment
The initial assessment is performed shortly after the patient is admitted
to a health careagency or service.
Focused Assessment
In a focused assessment, the nurse gathers data about a specific problem
that has already been identified. Helpful questions include:
•What are your signs and symptoms? • When did they start? • Were you
doing anything different than usual when they started? • What makes your

, symptoms better? Worse? • Are you taking any remedies (medical or
natural) for your symptoms?

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Rasmussen College: NUR 2115 summer Fundamentals of nursing exam 2 study guide,100% CORRECT

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