Chapter 4 The Nursing Process and Decision Making

What is the difference between the role of the RN and the role of the LPN/LVN in the nursing process?
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What is the difference between the role of the RN and the role of the LPN/LVN in the nursing process?
all the steps of
the nursing process, from assessment through evaluation, are
the responsibility of the RN. This includes outcome identification
in addition to planning.
What does ADPIE stand for
• Assessment is the gathering of information through signs and symptoms, patient history, and objective findings. Just as a physician gathers information by performing a physical examination and a patient history, the nurse gathers information
about the patient through asking questions (interviewing),
performing a head-to-toe assessment, and reviewing
laboratory and diagnostic tests.
• Diagnosis is the formulation of nursing diagnoses through analysis of the assessment information that you have gathered. The nursing diagnoses are related to the needs or problems the patient is experiencing. These are completely
different than medical diagnoses and are selected based on
definitions and defining characteristics.
• Planning is the process of determining priorities and what
nursing actions should be performed to help resolve or
manage each patient problem. In addition, the nurse determines
expected outcomes for the patient to meet for
the nursing diagnosis to be resolved, as well as a realistic
time frame for that to occur. The nurse then decides on
appropriate interventions to resolve each patient problem
or nursing diagnosis.
• Implementation is the process of taking actions to resolve
the patient's problems, the nursing diagnoses. These actions
are also called interventions. When the nurse performs
these interventions, it is called implementation. The nurse
implements the plan to help resolve the patient's problems.
• Evaluation is performed when the nurse reflects on the interventions
he or she has performed and decides if they
have brought the patient closer to achieving the goals and
outcomes set in the planning step. If not, the nurse then revises
and changes the interventions and
List three ways to obtain assessment data
Interviewing, which involves asking questions, listening,
and using both verbal and nonverbal communication skills. Performing a focused body system assessment to determine deviations from normal in the patient's physical condition. Reviewing the results of laboratory and diagnostic tests to determine problems and needs caused by abnormal findings.
How do nurses decide which nursing diagnoses have the highest priority
One tool is Maslow's Hierarchy of Human Needs.
Write a three-part nursing diagnosis for a patient with constipation
Write a three-part nursing diagnosis for a patient with constipation. If a patient was complaining of constipation, the nurse would assess the date of the last bowel movement and assess the abdomen.
The nurse would use independent interventions to help promote peristalsis, such as increasing fluid intake, encouraging high-fiber foods, and assisting with ambulation if allowed. The nurse also would administer laxatives or stool softeners as ordered by the physician. If the patient still was unable to
have a bowel movement and further orders were needed, the nurse would call the physician to obtain an order to administer an enema to the patient. Nurses always need an order from a health-care provider for diet, activity level, medications, IV therapy, treatments, diagnostic tests, and discharge
What types of care plans are available
Student Care Plans, Computerized care plans, standardized care plans, Multidisciplinary Care Plans, critical pathways, concept maps
Why do students write care plans
Student care plans have been used to help students make connections between the patient's medical diagnoses, medications, laboratory and diagnostic
tests, assessment data, nursing diagnoses, nursing orders or interventions, and evaluations. They also help sharpen Critical thinking and nursing decision making skills.
Which parts of a care plan can be done before your clinical experience and which parts must be done after you have met the patient? Before meeting
Step 1—Research Step 2—Possible Nursing Diagnoses Step 3—Expected Outcomes Step 4—Develop Your Interventions. After meeting, Step 5—Meet and Assess the Patient Step 6—Evaluate Your Nursing Diagnoses Step 7—Implement Your Interventions Step 8—Evaluate Your Care Plan
Which of the following are examples of activities in
which a nurse would need to use critical thinking?

a. Prioritizing patient care
b. Administering medications
c. Writing nursing orders
d. Questioning the appropriateness of an order
e. Starting an IV infusion
a. Prioritizing patient care
b. Administering medications
c. Writing nursing orders
d. Questioning the appropriateness of an order
e. Starting an IV infusion

Answer-All of them
2. Which of these is considered subjective data?
a. The patient is resting on his side.
b. The patient complains of a headache.
c. The patient ambulated to the bathroom with
assistance.
d. The patient's mother states that he does not eat well.
b. The patient complains of a headache.

d. The patient's mother states that he does not eat well.
3. Given that all of the following are appropriate nursing Diagnoses for your patient, which would be the priority? a. Ineffective coping b. Sedentary lifestyle c. Risk for loneliness d. Self-care deficit: bathingd. Self-care deficit: bathing4. Which of these nursing diagnoses is correctly written? a. Readiness for enhanced knowledge related to problems with diabetes b. Risk for injury related to poor balance when walking c. Risk for falls as manifested by frequent falls in the past d. Anxiety and fearb. Risk for injury related to poor balance when walkingnursing processa decision-making framework used by all nurses to determine the needs of their patients and to decide how to care for them.care plandocumented plan for giving patient care and includes physician's orders, nursing diagnoses, and nursing orderscritical thinkingcritical thinking is using skillful reasoning and logical thought to determine the merits of a belief or action.Objective datathose things that you can observe through your senses of hearing, sight, smell, and touch.subjective dataInformation that is known only to the patient and family members isprimary dataWhen the patient provides information, it is considered primary data.secondary dataobtain information from family members, friends, and the patient's chart, it is considered secondary data.Inspectionwhich is the visual examination of the patient's body for rashes, breaks in the skin, and normal appearance of eyes, ears, nose, mouth, limbs, and genitalsPalpationPalpation, which is touching or feeling the torso and limbs for pulses, abnormal lumps, temperature, moisture, and vibrationsAuscultationAuscultation, or listening for abnormal sounds in the lungs, heart, or bowelsPercussionPercussion, or using tapping movements to detect abnormalities of the internal organsMaslow's Hierarchy of Human Needs#1 Physiological Food, air, water, temperature regulation, elimination, rest, sex, and physical activity #2 Safety and security Protection, emotional and physical safety and security, order, law, stability, shelter #3 Love and belonging #4 Self-esteem #5 Cognitive #6 Aesthetic #7 Self actualization #8 Transcendence5 Components of Maslow'sbiological and physiological needs, safety needs, belongingness and love needs, esteem needs, self-actualizationNursing GoalA nursing goal is the overall direction in which one must progress to improve a problem.Expected outcomesExpected outcomes are statements of measurable action for the patient within a specific time frame and in response to nursing interventions.Direct patient careperformed when the nurse interacts directly with the patientIndirect patient careperformed when the nurse provides assistance in a setting other than with the patientindependent interventionsAn independent intervention is one that registered nurses are licensed to prescribe, perform, or delegate based on their knowledge and skills. It does not require a provider's order. Knowing how, when, and why to perform an activity makes the action autonomous (independent). As a rule, nurses prescribe and perform independent interventions in response to a nursing diagnosis. Understand you are accountable (answerable) for your decisions and actions with regard to nursing diagnoses and independent interventions.dependent interventionsA dependent intervention is one that is prescribed by a physician or advanced practice nurse but carried out by the bedside nurse. Dependent interventions are usually orders for diagnostic tests, medications, treatments, IV therapy, diet, and activity. In addition to carrying out medical orders, you will be responsible for assessing the need for the order, explaining the activities to the patient, and evaluating the effectiveness of the order.interdependent (collaborative) interventionAn interdependent (collaborative) intervention is one that is carried out in collaboration with other health team members (e.g., physical therapists, dietitians, and physicians). Because nurses care for the whole person, their responsibilities often overlap with those of other team members.Evidence-based practice (EBP)Evidence-based practice (EBP) is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing it includes blending clinical judgment and expertise with the best available research evidence and patient characteristics and preferences. The goal of evidence-based practice is to identify the most effective and cost-efficient treatments for a particular disease, condition, or problem. Steps in the EBP process include the following: ■ Formulating an answerable question about prevention, diagnosis, prognosis (likely outcome), and interventions ■ Conducting a systematic review of published evidence (research) to fi nd studies that shed light on the desired topic ■ Evaluating or grading the quality of the evidence obtained. Quality involves validity (closeness to the truth), applicability (usefulness), and impact (extent of the effect). ■ Compiling and analyzing the data to prepare a structured report of the review ■ "Translating" the evidence into guidelines for practice ■ Integrating the guidelines and evidence with clinical expertise and the patient's preferences and characteristicsAssessmenta systematic process by which the nurse collects and analyzes data about a patientCase Managementassignment of a health care provider to oversee the progress and issues of a patientClinical Pathwaysmultidisciplinary plan in which clinical interventions are scheduled over time for high risk, high volume types of medical diagnosesDiagnosisidentification of a disease or condition by scientific evaluation of physical signs and symptomsEvaluationdetermination made about the extent to which identified outcomes have been met in the nursing care planwhat are the 4 types of assessments?initial assessment; focus assessment; time lapsed reassessment; and emergency assessmentwhat is the group that defines nursing diagnoses?North American Nursing Diagnosis Association (NANDA)how should nursing diagnoses be prioritized?according to Maslow's Hierarchy of Needs, e.g. physiologic needs first followed by the ascending steps of Maslow's pyramidwhat is another name for interventions?nursing orders (nursing actions by the nursing staff to help the patient achieve the stated goals)What are the 5 steps of the nursing process in order?1. Assessment. 2. Nursing Diagnosis. 3. Planning. 4. Implementing. 5. Evaluating.During the Assessment process, you ___________ from primary source (the patient) and secondary source (family, etc.)collect dataDuring the Assessment process, you have to (1)_______, (2)_________, and (3)_________ the data you have collected.1. Interpret. 2. Validate. 3. Analyze.During the Assessment process, you have to apply (1)_______________, personal knowledge, clinical experiences, and (2)__________________.1. Critical thinking. 2. Standards of practice.During the Assessment process, you will establish a database for the patient of perceived (1)__________, (2)__________, and (3)___________.1. needs. 2. health problems. 3. responses.What can guide you through your initial assessment and screening?Cues and InferencesWhat are 2 comprehensive assessment approaches?1. Gordon's Functional Health Patterns. 2. Problem Oriented Approach.What are the two types of data that you can collect?Subjective and ObjectiveWhat are "defining characteristics"?symptoms, subjective and objective data.What are some examples of Defining Characteristics?Pain level of 7 on scale of 1-10. Crying. Sweating. Heart Rate 66 and regular. "I hate to eat anything green". "Sometimes I bleed when I have a bowel movement". Black, tarry stoolsPES statements• The problem is the diagnostic concept or label based on the patients needs. • The etiology refers to the causative factor(s) and is connected to the diagnostic label by the words "related to." • The signs and symptoms include the data collected and the evidence used to support the diagnostic label. They are linked to the statement with the words "as evidenced by."nursing goaloverall direction in which one must progress to improve a problemMind MapsConcept maps, also known as "mind maps," can be used to diagram and connect data about any subject. They also can be used to organize and plan nursing care, in effect making them a care plan as well. When you use a concept map to plan care, you still use the nursing process as your basis for decision making.NotesThe steps of the nursing process are assessment, diagnosis,planning, intervention, and evaluation. RNs participate in all aspects of the nursing process. LPNs/LVNs contribute to assessment and diagnosis, and participate in planning, intervention, and evaluation.notesNursing diagnoses may be one-, two-, or three-part statements. All contain a diagnostic label. Two-part statements also contain an etiology, and three-part statements contain both of these plus defining characteristics exhibited by the patient.NotesInterventions are nursing actions taken to resolve the nursing diagnosis. When the nurse performs these interventions, it is called implementation