Chapter 14-19

Question 1

Systematic

Answer 1

Part of an ordered sequence of activities

Question 2

Dynamic

Answer 2

Great interaction and overlapping among the five steps.

Question 3

Interpersonal

Answer 3

Human being is always at the heart of nursing.

Question 4

Outcome Oriented

Answer 4

Nurses and clients work together to identify outcomes.

Question 5

Universally Applicable

Answer 5

A framework for all nursing activities

Question 6

Benefits of the nursing process

Answer 6

Client
-Scientifically based, holistic individualized client care
-Continuity of care
-Clear, efficient, cost-effective plan of action

Nurse
-Opportunity to work collaboratively with other healthcare workers
-Satisfaction of making a difference in lives of clients
-Opportunity to grow professionally

Question 7

Critical Thinking & Clinical Reasoning

Answer 7

• is purposeful, informed, outcome-focused thinking
  -is driven by client, family, and community needs
  -uses both intuition and logic, based on knowledge, skills, and experience
  -requires strategies that make the most of human potential
  -is constantly reevaluating, self-correcting, and striving to improve.

Question 8

Assessment

Answer 8

-Systematic, dynamic way to collect and analyze data about a client
-includes physiological, psychological, sociocultural, spiritual, economic, and life-style factors.
-primary source of information is from the client

Question 9

Types of Assessments

• Initial Nursing Assessment

Answer 9

-Shortly performed after client is admitted to the health care facility

Question 10

Types of Assessments

-Focused Assessment

Answer 10

-information gathered about a diagnosed condition

Question 11

Types of Assessments

-Emergency Assessment

Answer 11

-Client presents with physiological crisis to identify life-threatening problem

Question 12

Types of Assessments

-Time-lapsed Assessment

Answer 12

-compares a current assessment to a baseline assessment

Question 13

Data Collection
(Purpose)

Answer 13

Purposes
-Health Status
-Health problem identification

Question 14

Data Collection
(Methods of Collection)

Answer 14

-Examination
-Observation
-Interviewing

Question 14

Data Collection
(Types)

Answer 14

1. Subjective
2. Objective

Question 15

Data Collection
(Characteristics)

Answer 15

-Purposeful
-Complete
-Factual & Accurate
-Relevant

Question 16

Data Collection
(Sources)

Answer 16

• Client
  -Family/Significant others
• Client Record
  -Other healthcare professionals

Question 17

Objective Data

Answer 17

• Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them
  (For example, elevated temperature, skin moisture, vomiting)

Question 18

Subjective Data

Answer 18

-information perceived only by the affected person
(For example, pain experience, feeling dizzy, feeling anxious)

Question 19

The Skill of Nursing Observation

Answer 19

1. Determines the client’s current responses (physical and emotional)
2. Determines the client’s current ability to manage care.
3. Determines the immediate environment and its safety.
4. Determines the larger environment (hospital and community)

Question 20

Successful Interview Techniques

Answer 20

1. Focus on the client during the interview
2. Listen to the client attentively.
3. Ask about client’s main problem first.
4. Pose questions and comments in appropriate manner.
5. Avoid comments and questions that impede communication.
6. Use silence and touch appropriately.

Question 21

Type of Questions used in Interviews

Answer 21

1. Open-ended-allow client to verbalize freely.
2. Closed- elicit specific information.
3. Validating- Validate what is heard.
4. Clarifying- avert misconceptions.
5. Reflective- encourage client to elaborate on thoughts and feelings.
6. Sequencing- place events in chronological order
7. Directing- Obtain more client information.

Question 22

Documentation of Data

Answer 22

1. Immediately give verbal reporting of data whenever a critical change in the client’s health status is assessed.
2. Enter initial database into computer or record in ink on designated forms the same day client is admitted.
3. Summarize objective and subjective data in concise, comprehensive, and easily retrievable manner.
4. Use good grammar and standard medical abbreviations.
5. Whenever possible use client’s own words.
6. Avoid nonspecific terms subject to individual interpretation or definition.

Question 23

Nurse Concerns and Responsibilities

Answer 23

1. Recognizing signs and symptoms of common health problems and those that may indicate the need for more expert diagnosis.
2. Predicting problems in those at risk and taking steps to manage risks and prevent complications.
3. Identifying human responses and promoting optimum function, independence, and quality of life.
4. Initiating actions and referrals in a timely way to ensure appropriate, qualified treatment.

Question 24

Purpose of the Diagnosing Step

Answer 24

1. Identify how an individual, group, or community responds to actual or potential health and life processes. 2. Identify factors that contribute to, or cause, health problems (etiologies) 3. Identify resources or strengths upon which the individual, group, or community can draw to prevent or resolve problems.

Question 25

Types of Diagnoses Nursing Diagnosis

Answer 25

-Describes client problems nurses can treat independently

Question 26

Types of Diagnoses Medical Diagnoses

Answer 26

-describes problems for which the physician directs the primary treatment

Question 27

Types of Diagnoses Collaborative Problems

Answer 27

-managed by using physician-prescribed and nursing-prescribed interventions

Question 28

Steps of Data Interpretation & Analysis

Answer 28

1. Recognizing significant data (comparing data to standards) 2. Recognizing patterns and clusters 3. Identifying strengths and problems 4. Reaching conclusions -No problem -Possible problem -Actual or potential problem -Clinical problem other than nursing diagnosis

Question 29

Formulation of Nursing Diagnosis *Problem

Answer 29

identifies what is unhealthy about client -Addresses the human response -NANDA (North American Nursing Diagnosis Association)

Question 30

Formulation of Nursing Diagnosis *Etiology

Answer 30

identifies factors maintaining the unhealthy state -related to (r/t) Example: Acute pain r/t myocardial ischemia

Question 31

Formulation of Nursing Diagnosis *Defining Characteristics

Answer 31

identifies the subjective and objective data that signal the existence of a problem. -As evidence by (AEB) Example: AEB c/o radiating chest pain to neck and left jaw

Question 32

Goal of Outcome Identification & Planning Step

Answer 32

1. Establish priorities 2. Identify and write expected client outcomes. SMART GOALS: -Specific -Measurable -Attainable -Relevant -Time bound 3. Select evidence-based nursing interventions. 4. Communicate the plan of care

Question 33

SMART GOALS

Answer 33

-Specific -Measurable -Attainable -Relevant -Time bound

Question 34

Elements of Comprehensive planning -Initial

Answer 34

1. Developed by the nurse who performs the nursing history and physical assessment. 2. Addresses each problem listed in the prioritized nursing diagnoses. 3. Identifies appropriate client goals and related nursing care.

Question 35

Elements of Comprehensive planning -Ongoing

Answer 35

1. Carried out by any nurse who interacts with a client. 2. Keeps the plan up to date. 3. States nursing diagnoses more clearly. 4. Develops new diagnoses. 5. Makes outcomes more realistic and develops new outcomes as needed. 6. Identifies nursing interventions to accomplish client goals

Question 36

Elements of Comprehensive planning -Discharge

Answer 36

1. Carried out by the nurse who worked most closely with the client. 2. Begins when the client is admitted for treatment. 3. Uses teaching and counseling skills effectively to ensure home care behaviors are performed competently.

Question 37

Types of Nursing Interventions Nurse-initiated

Answer 37

actions performed by a nurse without a physician's order -Independent actions -protocols -standing orders

Question 38

Types of Nursing Interventions Physician-initiated

Answer 38

actions initiated by a physician in response to a medical diagnosis but carried out by a nurse under doctor's orders. -dependent actions

Question 39

Types of Nursing Interventions Collaborative

Answer 39

treatments initiated by other providers and carried out by a nurse. -dependent actions

Question 40

Evaluation of Nursing Interventions

Answer 40

1. Were the goals met? -No further interventions required -Ongoing monitoring 2. If goals were not met? -Does the nurse need to change or revise interventions?

Question 41

Essentials of Effective Delegation

Answer 41

1. Know your state and institutional policies on delegation. 2. Be clear on the differences between nursing process and nursing task. 3. Know the training and background of the unlicensed assistive personnel. 4. Know the client's needs and what he or she is at risk for. 5. Know what clinical cues the UAP should be alert for and why. 6. Assess which tasks can be safely delegated.

Question 42

Rights of Delegation

Answer 42

1. Right Person 2. Right Task 3. Right Circumstance 4. Right Directions 5. Right Communication 6. Right Supervision 7. Right Evaluation