Identifying Clinical Problems in Nursing Practice 1

Question 1

What is nursing practice?

Answer 1

Problem solving approach to gather information/scientific data

Question 2

The primary purpose of the nursing process?

Answer 2

to assist nurses to manage patient care in a scientific and creative manner

Based on the scientific problem solving method

Question 3

Steps of nursing process?

Answer 3

1. assessment and diagnoses
2. planning
3. implementation
4. evaluation

Question 4

assessment and diagnoses phase?

Answer 4

Collecting and analyzing assessment data in order to identify self-care deficits (nursing diagnoses)

Question 5

planning phase?

Answer 5

Designing plan of care that is tailored to the patient’s problems:
How to prevent, reduce, resolve problems

how to implement nursing interventions

How to support patient’s self care abilities

Question 6

implementation phase?

Answer 6

Carrying out planned nursing interventions

Question 7

evaluation phase?

Answer 7

Judgement of the effectiveness of nursing care to meet patient goals:

Were the goals achieved?

Question 8

Essential Elements of the Nursing Process?

Answer 8

Problem-oriented
Dynamic
patient-centered 
Goal-directed
 planned
 creative
 cyclic

Question 9

purpose of data collection?

Answer 9

identify areas in which nursing intervention is required

directed to specific problems or needs

Question 10

Types of Data Collected?

Answer 10

subjective data

objective data

self-care practices (SCP) data

lab/chart data

Question 11

Techniques Used to Collect Data?

Answer 11

Interview
Physical Examination Techniques:

inspection-observe/look/smell
palpation-touch
percussion-tapping with hands
auscultation-listen with stethoscope

Question 12

objective Data?

Answer 12

information about a person that can be perceived, measured or observed by another person.

Examples of objective data, temp., weight, appearance

Question 13

subjective data?

Answer 13

info is reported by patient

Examples: pain, fatigue

Question 14

SCP Data?

Answer 14

Information pertaining to the practices the patient would normally carryout in order to meet his/her self-care requisites.

Question 15

lab/chart Data?

Answer 15

Information from the patient’s chart including:
Blood work results
Results of diagnostic tests
Consults/note from other members of the health care team.
Information from progress notes.

Question 16

Basic Conditioning Factors (BCF)?

Answer 16

age
 sex
 pattern’s of living
 sociocultural orientation
 developmental state
 health state
 family system factors
 health care system factors

Part of collecting your data base

Question 17

Making Inferences?

Answer 17

Your ability to identify cues and make inferences is influenced by:

your observational/assessment skills
your nursing knowledge
your nursing expertise

Question 18

What is inference?

Answer 18

How you interpret or perceive a cue – the conclusion you draw about the cue – is called an inference.

ASSUMPTION

Question 19

Validating Data?

Answer 19

ensure that assessment information is complete, accurate and factual

Eliminate any errors you may have

identify missing key information

Question 20

When to validate data?

Answer 20

when data conflicts

patient seems odd/unusual

Question 21

Clustering Data?

Answer 21

Organizing your data using the tools from orem’s model helps you to cluster your data

No tools do all of the clustering you need to do to understand and identify every problem.

You need to think about the relationships among the pieces of data and among the self-care requisites

Question 22

Action Demand?

Answer 22

Analyze all of the information and draw a conclusion regarding the situation.

This involves the generation of an action demand related to the self-care requisite of concern.

Consists of these two components:

1) action demand statement (ADS) (synthesis statement)
2) actions to be taken

Question 23

How to write the ADS?

Answer 23

verb + USCR + in a + age + sex of the patient + story that makes it particular

Question 24

Action demand; actions to be taken

Answer 24

Actions to be taken:

What needs to be done to meet the goal described in the synthesis statement.

Should be based on sound scientific rationale

Question 25

Example –Action Demand

Answer 25

Action Demand Statement :
Decrease risk of injury in a 72 year old gentleman who is blind and experiences orthostatic hypotension.

Actions:

1) changing position slowly
2) changing position in stages
3) drinking 2-2.5 liters/day

Question 26

Information in patient’s data base?

Answer 26

Health problems and responses to these problems, name, age, sex, place of birth, family support system

Question 27

Sources of data?

Answer 27

Client
Family/significant other
Health care team
Medical records

Question 28

Methods for gathering data?

Answer 28

Interview

Physical examination

Question 29

Techniques used when performing physical examination?

Answer 29

Inspection/smell
Palpation
Percussion
Auscultation
Vital signs
Height
Weight

Question 30

What is data validation?

Answer 30

Compare data with another source of data to determine accuracy

Question 31

Data organization involves?

Answer 31

Organizing data according to patterns and cues

Question 32

Data clustering involves?

Answer 32

Set of signs and symptoms grouped together in a logical way