Keiser University> NUR 1022C Fundamentals Final
Review/ NUR-1022C Fundamentals Final Review;
Complete Answered (all)
Objectives - ANSWER •Describe the components of the nursing process.
•Develop the components of the nursing diagnosis (patient problem).
•Discuss dependent, independent, and interdependent nursing interventions.
•Distinguish between measurable and non-measurable goals and interventions.
•Identify objective and subjective methods of evaluating the plan of care.
What is the nursing process? - ANSWER •Problem solving process (how we think
like nurses)
•Based on the scientific method
•Gather data (Assess first)
•Identify the problem (nursing diagnosis)
•Hypothesis solution (Come up with a goal)
•Test out the hypothesis (do the interventions work)
•Evaluate the results (Evaluate, and accommodate plan of care reassess if needed)
What is the nursing process? - ANSWER •The way one thinks like a nurse
(the nursing problem)
•Not the care plan - not the charting
Nursing is an autonomist profession making independent decisions
Why do we need to know it? - ANSWER •Conceptual framework of all nursing
curricula
•Nurse Practice Acts
•Standards of Clinical Practice of ANA
•The Joint Commission (JCAHO)
(All built around the nursing process)
When Do We Use the Nursing Process? - ANSWER •Every contact we have with a
patient
•Not just the formal written care plan
•Expert nurses unaware of separate steps
•It has become integrated into their thinking
(PT usually has multiple illnesses especially the elderly; always accessing and
reassessing pt status)
The five steps of the nursing process - ANSWER •Assessment (Assess pt)
•Diagnosis (analysis) (nursing problem based on assessment)
•Planning (goal Patient Centered/Intervention)
•Implementation(Implement them topee results)
•Evaluation (checking to see if the implementations work)
Priorities change
, Assessment - ANSWER •View client holistically
•Physical, developmental, cognitive, psychosocial, spiritual (looking at the patient as
a whole mind,body,spirit,development, how they think)
•Avoid assumptions (do a full thorough assessment)
psychosocial - ANSWER Describing the relation of the individual's emotional needs
to the social environment
Assessment - ANSWER •Data collection
•Sources of data
•Patient
•Always your primary source if capable of providing data**** Always pt centered care
•Family (Secondary if pt cnt communicate)
•Diagnostic tests (lab results and medications tells a lot about a pt health)
•Previous records
Assessment - ANSWER •Methods of data collection
•Observation (looking always doing )
•Interview (talking asking ?)
•Examination (test)
•Format - organized and comprehensive
(Health history, morning head to toe assessment and do more focused assessments
later in the day depending on the system and whats going on with the patient)
•Nursing admission
•Focused assessments
Assessment - ANSWER •What kind of data are we collecting?
•Subjective versus objective data
Subjective what pt says how they feel
Objective-measurable/observed
•Avoid judgments, opinions, or conclusions
Subjective data - ANSWER •What the patient states
•Feelings and perceptions
•"I feel sick to my stomach."
•"I wish I was home."
•"I have a burning pain in my side."
•"My heart feels like it is racing."
Objective data - ANSWER •Things that are observable and measurable by the
examiner
•BP 110/70
•Rash on right arm
•Ambulates with cane
•425mL clear, yellow urine
Subjective,Objective, Conclusion? - ANSWER •Client states that the pain is 8 on 0-
10 scale (S)
•75mL dark amber urine (O)
•Confused elderly white male (conclusion)
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