And its application for the December 2007 Nurse Licensure Examination

The Nursing Process

Dervid Santos Jungco R.N

The Facts :
45 Items in the December 2006 board examination are all about the Nursing Process. In the Nursing practice 1 of the June 2007 board examination, 20 out of 100 questions directly talks about the steps of the Nursing process. The steps of the Nursing process is integrated not only in NP1 but also in NP2,NP3,NP4 and NP5. Planning, particularly prioritization, is the most frequently asked question among all components of the Nursing process in both the previous board examinations [December and June]. Nursing process is one of the most essential topics, if not the most important, that needs to be mastered by anyone that will take the December 2007 board examination.

The Nursing Process

Nursing Process is defined as systematic, rational method of planning and providing individualized nursing care.

Characteristic of the Nursing Process

1. Systematic 2. Skill and knowledge based 3. Client Centered

4. Goal Oriented
5. Dynamic 6. Cyclical 7. Collaborative 8. Universal 9. Prioritized

The Nursing Process

The Nursing process is composed of:

1. Assessment 1. Collect data 2. Organize 3. Validate 4. Record

Questions
1. The nursing process is said to be dynamic, What makes it dynamic?

A. Every patient is a unique physical, emotional, social and spiritual being B. The patient participate in the over all nursing care plan C. Nursing practice is expanding in the light of modern developments that takes place D. The health status of the patient is constantly changing and the nurse must be cognizant and responsive to these changes 2. One of the characteristic of the nursing process is that it is based on prioritization. Given these clients, Priority attention should be given to which of the following? A. Linda, who shows severe anxiety due to trauma of the accident B. Ryan, post thyroidectomy patient who is showing an increasing edema of the neck C. Noel, who has lacerations of the arms with mild bleeding D. Andy, whose left ankle swelled and has some abrasions

Questions
3. An incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area. The best nursing goal for this client is to: A. Make sure that the bed linen is always dry B. Frequently check the bed for wetness and always keep it dry

C. Place a rubber sheet under the clients buttocks

D. Keep the patient clean and dry 4. A nurse is changing the central line dressing of a client receiving total parenteral nutrition (TPN). The nurse notes that the catheter insertion site appears reddened. The nurse next assesses which of the following? A. Tightness of tubing connections B. Client's temperature C. Expiration date on bag D. Time of last dressing change

Questions
5. Which of the following should be given the HIGHEST PRIORITY before physical examination is done to a patient? A. preparation of the equipment B. preparation of the environment

C. preparation of the patient

D. preparation of the nurse 6. During the assessment phase of the nursing process, the nurse is concerned with:

A. interpreting data
B. designing nursing strategies C. establishing a data base D. comparing client responses with the anticipated outcome

The Nursing Process

ASSESSMENT

Assessment

When an apple is cut, others see seeds in the apple. We, as nurses, see apples in the seeds. - Martha Rogers

Assessment
4 types of assessment 1. Initial or Database assessment 2. Focus or Ongoing assessment 3. Emergency assessment 4. Time lapsed assessment

Assessment Methods
1. Observation - To gather data using the 5 senses

2. Interview
- Is a planned communication with a purpose - Two approach includes directive and non directive 3. Physical Examination - A systematic method of data collection that uses the techniques of inspection, percussion, palpation and auscultation

Assessment Process
I. Collection of data Types of Data 1. Subjective 2. Objective Sources of Data 1. Primary 2. Secondary Subjective or Objective? 1. Blood pressure 2. Toe necrosis 3. Pain 4. Anxiety

Primary or Secondary?
1. Medical records 2. Support people 3. Client

Assessment Process
II. Organization of data 1. NANDA 9 human response pattern

2.Gordons typology of 11 functional health problems

3. Orems self care model 4. Roys adaptation model 5. Body systems model 6. Maslows hierarchy of needs 7. Eriksons psychosocial theory 8. Freuds psychosexual theory

Assessment Process
HUMAN RESPONSE PATTERNS 1. CHOOSING. 2. COMMUNICATING. 3. EXCHANGING. 4. FEELING. 5. KNOWING. 6. MOVING. 7. PERCEIVING. 8. RELATING. 9. VALUING. The following are assessment on Mang Javier, Organize the following data using NANDAS 9 human response patterns. 1. BP of 90/60

2. RR of 120
3. Urinary output of 20 cc/hr 4. HCT of 58% 5. Jehovas witness 6. Blue cross member 7. Disoriented, Lethargic 8. Ang sakit ng dibdib ko

Assessment Process
III. Validation of data [ Avoid premature closure ] Mang Domingo, a newly admitted client is seen by Nurse Budek. The client is holding and rubbing his jaw. CUE : INFERENCE :

VALIDATION QUESTION :

Assessment Process
IV. Recording of Data - serve as a vehicle for communication Characteristic of good recording 1. Factual 2. Actual 3. Prompt 4. Accurate 5. Complete Good or bad recording? 1. The client has a good appetite 2. The client states that she doesnt feel very well

3. Patient is Uncooperative when taking the medication

4. The clients skin is moist and cool 5. Small pressure ulcer noted on the left leg 6. Client is febrile

Questions
1. Objective data are also known as? A. Covert data B. Inferences C. Overt data D. Symptoms 2. Data or information obtained from the assessment of a patient is primarily used by nurse to: A. Ascertain the patients response to health problems B. Assist in constructing the taxonomy of nursing intervention C. Determine the effectiveness of the doctors order

D. Identify the patients disease process

Questions
3. What is an example of a subjective data? A. Color of wound drainage B. Odor of breath

C. Respiration of 14 breaths/minute
D. The patients statement of I feel sick to my stomach 4. Which of the following chart entries are not acceptable?

A. Patient states It hurts right here (Pointing to the chest)

B. Patient ambulated to bathroom C. Vital signs 130/70; 84; 20; 36 D. Pain relieved by Nitroglycerine gr 1/150 sublingually

Questions
5. Which of the following is the least nursing activity in performing assessment of the patient? A. laboratory test B. physical examination C. Health history D. systemic review

6. The MOST important initial nursing approach when admitting client is to: A. introduce the client to the ward staff B. orient the client to the physical set up of the unit C. identify the most immediate needs of the client and implement the necessary intervention D. take V/S from baseline assessment

Questions
7. You want to know the sleeping pattern of Mr. Ong during the past few

days, You will:

A. interview the clients and relatives B. take his BP before sleeping and upon waking up C. observe his sleeping pattern over a period of time D. perform physical assessment 8. When gathering baseline data, the BEST way for you to check if the client has pedal edema is to: A. talk to the relatives B. interview the client C. do auscultation D. do a physical assessment

Questions
9. To get accurate information about the quality of pain the patient is experiencing, which of the following statements would be most appropriate? A. What cause you the pain? B. Have you taken something to relieve the pain? C. Tell me what your pain feels like D. Is it stabbing or radiating pain? 10. Mr. Regalado says he has trouble going to sleep. In order to plan your nursing intervention you will: A. Observe his sleeping patterns for the next few days B. Ask him what do he mean by this statement C. check his physical environment to decrease noise level D. Take his blood pressure before sleeping and upon waking up

Questions
11. This is a SOAP recording of the patients problem of Nervousness. Which is the subjective data? A. Mr. Z was nervous during the interview, he moved frequently in the bed and his palms were sweaty. B. Mr. Z does not seem to tolerate stress too well which will aggravate his cardiac condition. He understands Little about his health which may be increasing his state of anxiety. C. I am nervous at times. Exerts himself physically and is hesitant to discuss problems. D. Mr. Z should: 1. demonstrate an ability to cope with nervousness

2. demonstrate an understanding of the relationship between his nervousness and cardiac condition

The Nursing Process

DIAGNOSIS

Diagnosis

The focus of nursing is in our clients response to their illness, the treatment they are receiving and the situation they are in. - Carmencita M. Abaquin

What type of nursing diagnosis?

Diagnosis
The classification of disease, condition or human response based upon of upon scientific evaluation of signs and symptom, patient Hx, and Dxtic studies
Types of Nursing Diagnosis 1. Actual 2. High Risk

1. Urinary incontinence related to weak pelvic muscle, obesity and gravid uterus as evidenced by urine dribbling when coughing 2. Potential for enhanced organized infant behavior, related to prematurity and as manifested by response to visual and auditory stimuli 3. Risk for injury related to altered mobility and disorientation 4. Potential for enhanced parenting 5. Possible disturbed body image related to surgical operation 6. Risk for caregiver role strain related to discharge of family member with significant health care needs, economic instability and lack of respite care availability

3. Possible
4. Wellness

Format of the Nursing Diagnosis

1. Problem
- Clients health status and health problem - With qualifiers such as Altered, Impaired, Decreased, Ineffective, Acute and Chronic.

2. Etiology
- The Related factors if actual - Risk factor if high risk 3. Sign and Symptoms - Cluster of sign and symptoms that indicates the presence of the problem - sign and symptoms if actual - same as the etiology if high risk

Format of the Nursing Diagnosis

PES 1. Imbalanced nutrition less the body requirement related to increased metabolic demands as exhibited by body weight below 80% of the ideal. 2. Risk for injury directed to self related to feeling of worthlessness and helplessness

Medical VS Nursing Diagnosis

Medical: terminology used for a clinical judgment by the physician. Identifies or determines a specific disease, condition, or pathological state. Describes problems for which the physician directs the primary treatment Nursing: clinical judgment that identifies the clients responses to a health state, problem or condition. Describes patient problems nurses can treat independently

Steps in Nursing Diagnosis

S-

Assessment data: BP 90/60 CVP 4 cmH20 Hct 60% Weakness HR 110 RR 30 Lethargic Fatigue

CAN-

Pallor
Poor appetite Disoriented Dyspnea 20% above IBW

U/O 10 cc/hr
Hgb 10g/dl Restlessness Hx of Depression Suicidal

Guidelines for writing nursing diagnosis

Correct or incorrect? 1. Imbalanced nutrition : less than body requirement related to improper feeding of the Nurse 2. Impaired skin integrity related to bed sores 3. Nausea related to post surgical anesthesia 4. Diarrhea related to Laxative use 5. Self care deficit: Toileting related to inability to get OOB w/o help 6. Risk for ineffective airway clearance related to emphysema 7. Impaired verbal communication related to tracheostomy 8. Ineffective sexuality pattern related to homosexuality 9. Altered oral mucous membrane related to irritating agents 10. Pain related to severe headache

Questions
1. After assessing the client, The nurse should do which of the following next: A. Prioritize the clients problem B. Evaluate the clients response to the nursing intervention C. Determine the clients response to actual and potential health problems D. Come out with specific nursing intervention that would alleviate the clients problem

Questions

2. Which of the following is a correctly written actual nursing diagnosis? A. Impaired physical mobility as evidenced by decreased range of motion in left shoulder from 180 degrees to 190 degrees of flexion and extension related to left shoulder pain B. Ineffective airway clearance related to thickened bronchial secretions as evidenced by adventitious lung sounds over the periphery of the right and left lung field C. Potential for altered nutrition less than body requirements as evidenced by a 15 lb weight loss in 3 weeks

D. Risk for injury related to decreased oxygen level in the blood as evidenced by irritability and restlessness

Questions
3. Your client, who happens to be female resident of the barangay you are covering, is an adult survivor who states: Why couldnt I make him stop the abuse? If I were stronger person, I would have been able to make him stop. Maybe it was my fault to be abused. Based on this, which would be your most appropriate nursing diagnosis? A. social isolation B. anxiety C. chronic low self-esteem D. ineffective family coping

4. For the past 24 hours, TD with dry skin and dry mucous membranes has had a urine output of 600 m and a fluid intake of 800 ml. TDs urine is dark amber. These assessments indicate which nursing diagnosis?
A. Impaired urinary elimination

B. Excessive fluid volume

C. Deficient fluid volume D. Imbalanced nutrition: less than body requirement

Questions
5. Shortly after being admitted to the CCU for acute MI, JJ reports midsternal chest pain radiating down the left arm. You notice that JJ is restless, slightly diaphoretic, and has a temperature of 37.8 deg C, heart rate of 62 beats/min.; regular, slightly labored respirations at 26 breaths/min and a blood pressure of 150/90 mmHg. Which nursing diagnosis takes HIGHEST PRIORITY? A. decreased cardiac output C. acute pain

B. anxiety temperature

D. risk for imbalanced body

6. AW, 3 year old boy just sustained full thickness burns of the face, chest and neck. What will be your PRIORITY nursing diagnosis?

A. Risk for infection related to epidermal disruption

B. Impaired urinary elimination related to fluid loss C. Ineffective airway clearance related to edema D. Impaired body image related to physical appearance

Questions
7. BL was brought to the Emergency Room for severe left flank pain, nausea and vomiting. The physician gave a tentative diagnosis of right ureterolithiasis. As the nurse of BL which of the following nursing diagnosis will be your PRIORITY? A. imbalance nutrition: less than body requirements B. impaired urinary elimination C. acute pain D. risk for infection 8. A nurse is formulating a plan of care for a client receiving enteral feedings. The nurse identifies which nursing diagnosis as the highest priority for this client?

A. Altered nutrition, less than body requirements

B. High risk for aspiration C. High risk for fluid volume deficit D. Diarrhea

Questions
9. All of the following are applicable nursing diagnosis for a post mastectomy client except: A. Pain upon lying down B. Body Image Disturbance C. Potential for sexual dysfunction D. Self care deficit r/t immobility of the arm 10. While caring for a client who's immobile, the nurse documents the following information in the client's chart: "Turned client from side to back every 2 hours." "Skin intact; no redness noted." "Client up in chair three times today." "Improved skin turgor noted." Which nursing diagnosis accurately reflects this information? A. Risk for impaired skin integrity related to immobility B. Impaired skin integrity related to immobility

C. Constipation related to immobility

D. Disturbed body image related to immobility

OUTCOME IDENTIFICATION AND PLANNING

The Nursing Process

Planning
Planning is a deliberative, systematic phase of the nursing process that involves decision making and problem solving. In planning, the nurse End product -

Starts Types of Planning 1. Initial 2. Ongoing 3. Discharge

The Planning Process

Set Priorities Nursing Goals/Outcomes Intervention Selection Plan Writing = NCP Establish Communication

Setting Priority
Establishing preferential order for nursing strategies
Ranks the order of the nursing intervention in terms of which is most important for the clients needs Classified as: 1. High 2. Medium 3. Low

Prioritize! Sergio is brought to the emergency room after a barbecue grill accident wherein, he sustained deep partial thickness burn on his chest, trunk and right lower extremities. A singed nasal hair is also evident. The following are his POSSIBLE nursing diagnosis. 1. Pain

2. Fluid volume deficit

3. Ineffective airway clearance 4. Body Image disturbance Question : Which has the highest priority and the lowest priority?

Guidelines in prioritizing
1. Life threatening situation should be given the highest priority. 2. Use the principle of ABC. 3. Use Maslows Hierarchy of Needs. 4. Strictly follow the nursing process, ASSESS first before intervening. 5. Client first before the equipment.

6. In the board exam, Resources are never a factor. Always assume that there is unless the otherwise is stated.

Nursing Goals and Expected Outcomes

Difference? Within a week of nursing interventions, The clients nutritional status will improve as evidence by: 1. Adequate caloric consumption of at least 1,000 calories a day. 2. Minimal pain during eating. 3. Will gain 10 lbs by December 1.

Short term and Long term goals

Long-term requires a longer period to be achieved and may be used as discharge goals

Short-term may be accomplished in a short period of time

Question : A client with dependent personality disorder is working on goals of self care. Which of the following short term goals is most important to the clients everyday activities of daily living? A. Do all self care activities independently B. Write all activities in a journal for each day of the week C. Client will never be dependent on the nurse D. Determine activities that can be performed without help

Guidelines in writing goals and outcomes

Correct or Incorrect Goals/Outcome? 1. The nurse will explain complications related to anesthesia before discharge. 2. Allow the client to verbalize feelings related to depression during periods of communication 3. The client will be able to state all foods rich in potassium after the teaching session 4. The client will have an increase knowledge about nutrition after the teaching session 5. [Elderly client with late stage dementia] The client will jog at least 10 kilometers a day after discharge

6. The client will feel good

Intervention Selection
Refers to action the nurse needs to perform to achieved the desired goals and outcomes. Nurse-initiated actions performed by a nurse without a physicians order Physician-initiated actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctors orders Collaborative treatments carried out by a nurse initiated by other providers

Guidelines in selecting interventions

1. Active and Directive Eg: Apply hot water bag over the epigastric region for 30 minutes now VS The nurse will apply hot water bag on the epigastric region 2. Realistic

Eg: Communicate with the patient as frequent as possible when performing nursing intervention to help facilitate verbalization of feelings VS Encourage the verbalization of the clients feelings at all times
3. Concise Eg: Encourage intake of fluids by offering a glass of water every 3 hours VS Increase the clients fluid intake 4. Safe Eg: [Client with Menieres disease] Keep the side rails up and put the best at the lowest possible position VS Encourage the client to get up from bed and ambulate to the bathroom independently

Guidelines in selecting interventions

5. Based on the code of ethics Eg: Explore the clients feelings regarding blood transfusion. Assure him that the health care team knows his religious stand about receiving blood VS Inform the client about the need for blood transfusion, convince him that it is the only measure that can save his life. 6. Based on scientific principle and research Eg: Encourage intake of fluids by offering a glass of water every 3 hours Rationale : A hospitalized client is usually passive and dependent. The stress of hospitalization put burden on the client thus, providing an outlet for regressive behaviors. Offering a glass of water will increase the clients sense of control and at the same time, promote hydration.

Nursing Care Plan

Considered as the

Use as
Must be Written to

Types of NCPs 1. Kardex

2. Computer generated
3. Holographic/Student/Written

Questions
1. Which of the following objectives is written in behavioral terms?

A. Mang Carlos will know about diabetes related to foot care and the techniques and equipments necessary to carry it out B. Mang Carlos should learn about DM within the week C. Mang Carlos needs to understand the side effects of insulin D. Mang Carlos will be able to calculate in two days his insulin requirement based on blood glucose levels obtained from glucometer 2. Which of the following is the BEST rationale for written objectives?

A. ensure communication among staff members

B. facilitate evaluation of the nurses performance C. ensure learning on the part of the nurse D. document the quality of care

Questions
3. A main function of the nursing care plan is to: A. prepare the nurse for the shift worked B. serve as a record of financial charges C. serve as a vehicle for communication D. ensure that the message is received 4. Which of the following is true about discharge planning? A. basic discharge plans involve referral to community resources

B. All discharge plans involve referral to community resources

C. simple discharge plans involves use of a discharge planner D. complex discharge plans includes interdisciplinary collaboration

Questions
5. Ms. W.O. is found on the floor of her room. She fell while crawling over the side rails of her bed. She is unconscious and has a large laceration to the head that is bleeding profusely. The nurses priority action would be: A. apply direct pressure to the laceration to her head B. ensure the patient has an open airway C. notify the physician D. check the patients vital signs

6. When caring for TU after an exploratory chest surgery and pneumonectomy, your PRIORITY would be to maintain:

A. chest tube drainage B. blood replacement

C. ventilation exchange D. supplementary oxygen

Questions
7. This flip over card is usually kept in a portable file at the Nurse Station. It has 2 parts, The activity and treatment section and a nursing care plan section.
A. Discharge summary B. Medicine and treatment record C. Nursing health history D. Nursing kardex

8. When caring for DS, who sustained 40% severe flame burn yesterday, which among these interventions should be your PRIORITY?

A. provide a calm, efficient and safe environment

B. keep the body parts in good alignment to prevent contractures

C. assess for airway, breathing and circulation problems D. assess the injury for signs of sepsis

Questions
Situation 6: Eileen, 45 years old is admitted to the hospital with a diagnosis of renal calculi. She is experiencing severe flank pain, nauseated and with a temperature of 39 0C.

9. Given the above assessment data, the most immediate goal of the nurse would be which of the following? A. Prevent urinary complication B. maintains fluid and electrolytes

C. Alleviate pain
D. Alleviating nausea

IMPLEMENTING AND EVALUTATING

The Nursing Process

Implementing
Is the phase of the nursing process wherein the nurse puts the nursing care plan into action.

3 Ds of Implementation

D
D

Doing
3 Skills in performing the Nursing interventions 1. Cognitive 2. Interpersonal

3. Technical
Activities in Doing

1. Reassessing the client

2. Preparing the client 3. Preparing the equipment and supplies 4. Implementing the intervention

5. Communicating the nursing action

Delegating
Is defined as the process in which the manager assigns specific tasks or duties to workers with commensurate authority to perform the job

5 rights to delegation

Right task Right circumstances Right person Right direction/communication Right supervision

What cannot be delegated to UAP?

Initial and ongoing nursing assessment
Determination of nursing diagnoses, plans, evaluations Supervision and education of nursing personnel A nursing intervention requiring professional nursing knowledge, judgment and/or skill

Documenting
Is the process of printing or writing the nursing care performed.

[Documentation and Reporting is a separate discussion under Module 7 : Reporting and Documentation]

Evaluation
Is a planned, ongoing, purposeful activity of determining the progress of a client towards goal achievement and the effectiveness of the nursing care plan.

3 Types of evaluation 1. Ongoing

Activities in evaluation 1. Assess/Analyze

2. Intermittent
3. Terminal

2. Nursing Care Plan

3. Goals achievement

Evaluation
3 possible judgment during evaluation

Expected outcome: Absence of pallor and cyanosis on skin and mucus memberane Evaluation statement: Skin and mucus membrane not cyanotic, but still pale

Judgment:

1. Goal met 2. Goal partially met 3. Goal unmet

Expected outcome: Client will exhibit productive cough Evaluation statement: Cough productive of moderate amount of thick, yellow, pink tinged sputum Judgment: Expected outcome: Inhaling normal volume of air on incentive spirometer. Evaluation statement: Tidal volume of 250 ml Judgment:

Four Types of Outcomes Evaluated

1. Cognitive
2. Psychomotor 3. Affective 4. Physiologic 1. Linda, a diabetic client is being evaluated by the Nurse. Linda now demonstrates dexterity in measuring her blood sugar level using glucometer. In evaluating Linda, you know the she achieved improvement in: A. Cognitive B. Affective C. Physiologic D. Psychomotor

Questions
2. You continuously evaluate the clients adaptation to pain.
Which of the following behavior indicates appropriate adaptation? A. The client reports pain reduction and decreased activity

B. The client denies the existence of pain

C. The client distract himself during pain episodes D. The client reports independence from watchers 3. Which physiologic effect should the nurse expect in a client addicted to hallucinogens? A. Dilated pupils C. Bradycardia B. Constricted pupils D. Bradypnea

Questions
4. A patient is receiving a dose of Fentanyl for the management of Chronic pain. When administering the drug, which of the following is a potential side effect that you need to tell the client? A. Avoid driving or operating heavy machineries, The drug causes drowsiness. B. Avoid exercising, The drug causes Palpitation and Tachycardia C. Do not go to high places, the drug causes Tachypnea

D. Take a bath using cold water because the drug causes Flushed and warm skin
5. The following tasks can be safely delegated by a nurse to an UAP except: A. Transfer a client from bed to chair C. Change IV infusion

B. Irrigation of NGT

D. Taking Vital Signs

Questions
6. After one week of antidepressant medication, Jolina still manifests depression. The nurse evaluates this as:
A. Unusual because the action of antidepressant is immediate B. Unexpected because therapeutic effectiveness is always within a week C. Expected because therapeutic effectiveness takes 2 to 4 weeks D. Ineffective result because probably the drug dosage is inadequate

And its application for the December 2007 Nurse Licensure Examination

The Nursing Process

Dervid Santos Jungco R.N