Chapter 12-14 Nursing Process

Question 0

Purpose of the NANDA

Answer 0

Define, refine and promote a taxonomy of nursing terminology of the general use to professional nurses

Question 1

Components of nursing diagnosis

Answer 1

1. The problem and its definition
2. The etiology (related factors)
3. The defining characteristics (as evidence by)

Question 2

Nursing process vs Medical process

Answer 2

Nursing- holistic focus, teach for independence, involved with family individuals and groups.

Medical- disease focus, consults with nursing for planning ADLs.

Question 3

Describe the components of diagnosing

Answer 3

-refers to the reasoning process
-diagnosis is the statement or conclusion regarding the nature of a phenomenon
-standardized by the NANDA
-nursing dx= problem statement with NANDA
label + etiology

Question 4

Actual Dx

Answer 4

-Problem presents at the time of the assessment
-Presence of signs and symptoms
Example: anxiety, ineffective breathing pattern

Question 5

Risk Dx

Answer 5

-Problem does NOT exist
-Presence of risk factors are present and patient is more likely than other patients to develop problem
Example: someone is dizzy is at risk for falls

Question 6

Health Promotion Dx

Answer 6

-Preparedness to implement behaviors to improve their health condition
-Begin statement with “readiness for enhanced…nutrition”
Example: overweight patient with coronary disease ready to lose weight

Question 7

Wellness Dx

Answer 7

-Describes human responses to levels of wellness in an individual, family, or community.
Example: Readiness for enhance family coping

Question 8

Syndrome Dx

Answer 8

-Used when diagnosis is associated with a cluster of diagnoses
Example: Disuse Syndrome, rape-trauma syndrome

Question 9

Components of nursing Dx: problem statement (diagnostic label)

Answer 9

• Describes the client’s response to the health problem
• Qualifiers: deficient, impaired, decreased, ineffective
• Leads to outcome

Question 10

Components to nursing Dx: etiology (related factors and risk factors)

Answer 10

• Identifies one or more probable causes of the health problem
• Related to factors and risk factors
• Including all related to factors

Question 11

Components of a nursing Dx: defining characteristics

Answer 11

• Cluster of all signs and symptoms indicate the presence of a particular diagnostic label
• actual nursing diagnoses client’s have signs and symptoms

Question 12

Tips for writing good nursing Dx

Answer 12

• write it in respect to patient’s response
• use r/t NOT due to
• write Dx in legally advisable terms
• write without judgment
• avoid reversing parts
• avoid redundancy
• be clear and concise
• don’t use medical Dx
• don’t rename a medical condition to fit nursing Dx
• don’t state 2 problems at the same time

Question 13

Tips for writing outcomes and goals

Answer 13

• should be related to human response
• should be client centered begin with “the client will”
• should be clear and concise
• should be observable and measurable
• should be time limited
• should be realistic
• should be set together (nurse and patient)
• outcomes provide blueprint for evaluation

Question 14

Terms that are measurable vs nonmeasurable

Answer 14

• Measurable: identify, describe, state, demonstrate, verbalize, discuss
• Nonmeasurable: know, understand, appreciate, feel, think, accept

Question 15

Nursing intervention components

Answer 15

• focus on activities to promote, maintain, or restore health
• two types: independent and dependent
• assessment to determine health status
• diagnosis of responses requiring nursing interventions
• identification of nursing interventions to maintain or restore health
• implementation of measures to motivate, guide, support or teach family/client
• referrals as allowed by the Nurse Practice Act (social services, pastoral care)
• evaluation of client responses
• participation with consumers or other health care providers in improvement of health care system

Question 16

Tips for writing interventions

Answer 16

• must be dated and signed in the clinical area
• use precise action verbs (want something to be done)
• define who, what, where, when and how often
• must be consistent with plan of care–every intervention must meet the outcome that has been set
• only one assessment order allowed
• based on scientific principles

Question 17

Implantation: five activities

Answer 17

1. Reassessing the client
2. Determining the nurse’s need for assistance
3. Implementing nursing interventions
4. Supervising delegated care
5. Documenting nursing activities

Question 18

Evaluation

Answer 18

Look in book

Question 19

Steps in formulation a nursing diagnosis

Answer 19

Analyze the data
Identify health problems, risks, strengths
Formulation diagnostic statements

Question 20

Scientific rationale for nursing diagnosis

Answer 20

Based on scientific principles

Question 21

Steps for planning

Answer 21

Prioritize problems and diagnoses
Formulate goals and desired outcomes
Select nursing interventions
Write nursing intervention

Question 22

Process of implementing

Answer 22

Reassessing the client
Determine the nurses need for assistance
Implementing the nursing interventions
Supervising delegated care 
Documenting the nurses activities

Question 23

Process of evaluating

Answer 23

Collecting and comparing data related to desired outcomes
Relating nursing activities to outcomes
Drawing conclusions about problem status
Continuing, modifying or terminating the nursing care plan