Nursing Process Basics
What are the five steps of the nursing process?
Assessment
Analysis/Diagnosis
Planning
Implementation
Evaluation
What is subjective data?
Information the client reports about feelings, perceptions, or symptoms.
What is the purpose of analysis/diagnosis?
To identify patterns, compare data to standards, and determine client problems.
What occurs during implementation?
Performing, delegating, supervising, and documenting nursing interventions.
A client reports pain as 8/10. Which step is this?
Assessment
How is the nursing process best described?
A cyclical, critical-thinking, client-centered, problem-solving framework.
What is objective data?
Observable and measurable findings obtained through assessment.
What tool is commonly used to set priorities during planning?
Maslow’s Hierarchy of Basic Needs.
What types of interventions do nurses implement?
Nurse-initiated, provider-initiated, and collaborative.
A nurse identifies shallow breathing as a symptom related to pain. Which step is this?
Analysis/Diagnosis.
What type of reasoning does the nursing process use?
Scientific reasoning and critical thinking.
Which methods are used to collect assessment data?
Observation, interview, physical exam, diagnostics, and collaboration.
What is the difference between a goal and an outcome?
A goal describes desired status; an outcome is a measurable criterion.
What is an example of a nurse-initiated intervention?
Repositioning a client every 2 hr.
A nurse administers prescribed pain medication. Which step is this?
Implementation.
How does the nursing process distinguish nursing from medicine?
It focuses on nursing judgments, responses to health problems, and individualized care planning.
Who is the primary source of subjective data?
The client.
What characteristics must goals/outcomes have?
Client-centered, measurable, observable, time-limited, reasonable.
What is the focus of evaluation?
Determining whether client outcomes were met.
A nurse checks for pain relief 40 minutes after administering the medication. Which step is this?
Evaluation.
Which steps are combined for practical nurses (PNs)?
Assessment and analysis into one data collection step.
What must nurses do with data during assessment?
Validate, interpret, cluster, and document it accurately.
What is the end product of the planning step?
The nursing care plan (NCP).
What actions follow unmet outcomes?
Modify the plan of care, outcomes, or interventions.
A postoperative client has inadequate pain relief. What is the nurse’s first action?
Reassess the client to determine the cause of inadequate pain relief.