N200 Midterm Nursing Process Flashcards
The nursing process provides?
a common language and process for nurses to think through clients’ clinical problems while focusing on a particular client’s unique needs.
The nursing process is used to….
diagnose, and treat human responses to actual or potential health problems
What are the 5 steps in the nursing process?
ADPIE
Assessment: gather information about the client’s condition
Diagnosis: identify the client’s problem
Plan: set goals of care and desired outcomes and identify appropriate nursing actions
Implementation: perform the nursing actions identified in planning
Evaluation: detmerine if goals met and outomes achieved
With assessment, what is subjective data?
Interview and health history- what the patient tells you
With assessment, what is objective data?
what you see, includes:
Physical Exam
Diagnostic and Lab Data
Observation of client’s behavior- what you see
what is a data cluster?
set of signs or symptoms gathered during assessment that you group together in a logical way.
A related factor is
a condition, historical factor, or etiology that gives a context for the defining characteristics and shows a type of relationship with the nursing diagnosis
Collaborative Problems
Actual or potential physiological complication that nurses monitor to detect the onset of changes in a client’s status
PHYSIOLOGICAL complication that requires the nurse to use nursing and … to maximize pt outcomes
What is included in the diagnostic process
Analysis and Interpretation (Data Validation and Clustering; Derived from assessment)
Identification of Client Needs (Based on defining characteristics; Clinical criteria)
Formulation of Nursing Diagnosis
risk nursing diagnosis
describes human responses to health conditions or life processes that may develop in a vulnerable individual, family, or community
What are the 4 types of nursing diagnosis?
Actual nursing diagnosis
Risk nursing diagnosis
Health Promotion diagnosis
Wellness nursing diagnosis
health promotion nursing diagnosis
A health promotion nursing diagnosis is a clinical judgment of a person’s, family’s, or community’s motivation, desire, and readiness to increase well-being and actualize human health potential as expressed in their readiness to enhance specific health behaviors such as nutrition and exercise.
actual nursing diagnosis
describes human responses to health conditions or life processes that exist in an individual, family, or community.
etiology or related factor of a nursing diagnosis
The etiology or related factor of a nursing diagnosis is always within the domain of nursing practice and a condition that responds to nursing interventions.
diagnostic label
is the name of the nursing diagnosis as approved by NANDA International
nursing diagnosis format includes (4)
Diagnostic Label
Related Factors
Etiology
Risk Factors
The related factor
is identified from the patient’s assessment data and is the reason the patient is displaying the nursing diagnosis. The related factor is associated with a patient’s actual or potential response to the health problem and can change by using specific nursing interventions.
Related factors for NANDA-I diagnoses include what four categories?
- pathophysiological (biological or psychological),
- treatment-related,
- situational (environmental or personal)
- maturational
Where can errors occur in the diagnostic process?
Errors can occur in the diagnostic process during data collection data clustering, data interpretation and statement of the nursing diagnosis
Name 5 ways error can be avoided in the diagnostic process.
- Identify the client’s response, not the medical diagnosis.
- Identify a NANDA diagnostic statement rather than the symptom.
- Identify a treatable etiology rather than a clinical sign or chronic problem.
- Identify the problem caused by the treatment or diagnostic study rather than the treatment or study itself.
- Validate that measurable objective physical findings support subjective data
Name 5 ways error can be avoided in the diagnostic process (cont’d….)
- Identify the client response to the equipment rather than the equipment itself.
- Identify the client’s problems rather than your problems.
- Identify the client problem rather than the nursing intervention.
- Identify the client problem rather than the goal.
- Make professional rather than prejudicial judgments. say “pt declines X due to X” rather than “pt refuses…”
A nurse reviews data gathered regarding a patient's pain symptoms. The nurse compares the defining characteristics for acute pain with those for chronic pain and in the end selects acute pain as the correct diagnosis. This is an example of the nurse avoiding an error in: A. Data collection. B. Data clustering. C. Data interpretation. D. Making a diagnostic statement. Rationale
C. Data interpretation.
In the review of data, the nurse compares defining characteristics for the two nursing diagnoses and selects one based on the interpretation of data. Making a diagnostic statement is incorrect because the nurse has not included a related factor.
The nursing diagnosis readiness for enhanced communication is an example of a(n): A. Risk nursing diagnosis. B. Actual nursing diagnosis. C. Health promotion nursing diagnosis D. Wellness nursing diagnosis.
C. Health promotion nursing diagnosis
A patient’s readiness for enhanced communication is an example of a health-promotion diagnosis because it implies the patient’s motivation and desire to strengthen his health.
Which of the following are examples of collaborative problems? (Select all that apply.) A. Nausea B. Hemorrhage C. Wound infection D. Fear
Which of the following are examples of collaborative problems? (Select all that apply.)
B. Hemorrhage
C. Wound infection
collaborative problems, actual or potential physiological complications. Nurses typically monitor for these to detect changes in a patient’s status. Nausea and fear are both NANDA-I approved nursing diagnoses.
The following nursing diagnoses all apply to one patient. As the nurse adds these diagnoses to the care plan, which diagnoses will not include defining characteristics? A. Risk for aspiration B. Acute confusion C. Readiness for enhanced coping D. Sedentary lifestyle
A. Risk for aspiration
A risk diagnosis does not have defining characteristics, but instead risk factors. Risk factors are the environmental, physiological, psychological, genetic, or chemical elements that place a person at risk for a health problem.
Define Planning with regard to nursing diagnosis.
Client-centered goals are established and interventions are designed to achieve the goals.
What are the 4 steps to Designing nursing care for a client?
set priorities
determine goals
develop expected outcomes
formulate a plan of care
Expected Outcomes
- the specific, step-by-step objective that leads to attainment of the goal and the resolution of the etiology for the nursing diagnosis.
- Measurable change of the clients status in response to nursing care
What are the 3 types of Nursing INterventions?
Nurse-initiated interventions
Physician-initiated interventions
Collaborative interventions by ancillary personal, protocols and standing orders.
Implementation
describes the initiation of nursing behavior in which the actions necessary for achieving the goals and expected outcomes of nursing care are initiated and completed. Write how pt tolerated action
Implementation Process includes (4)
Reassessing the client
Organizing resources and care delivery
Anticipating and preventing complications
Communicating nursing interventions
What are the 3 implementation skills associated with the nursing process?
Cognitive skills
Interpersonal skills: family dynamics
Psychomotor skills
The evaluation step of the nursing process
measures the client’s response to nursing actions and the client’s progress toward achieving goals.
Describes?
A written guideline for client care used by all members of the nursing team
Coordinates nursing care, promotes continuity of care, and lists outcome criteria to be used in the evaluation of nursing care.
Communicates nursing priorities to other health care professionals
Decreases the risk of incomplete, incorrect, or inaccurate care
Nursing Care Plan
Describes?
Visual representation of client problems that show relationships to one another
Groups and categorizes nursing concepts for a holistic view of health care needs
Gather assessment data
Review references (textbooks, pathways,education materials)
Skeleton Diagram
Identify Diagnosis
Analyze relationships
Interventions and Evaluations
Concept Map
allow staff from all disciplines to develop integrated care plans for a projected length of stay or number of visits for clients.
Critical pathways
Consultation
is a process in which a specialist’s help is sought to identify ways to handle problems in client management or problems related to the planning and implementation of programs.
Discharge teaching and planning occurs the _____ the patient is admitted to the hospital.
MOMENT
Collaborative interventions,
or interdependent interventions, are therapies that require the combined knowledge, skill, and expertise of multiple health care professionals.
______are patient care management plans that provide the multidisciplinary health care team with the activities and tasks to be put into practice sequentially (over time); their main purpose is to deliver timely care at each phase of the care process for a specific type of patient
Critical pathways
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9 kg) and is partially immobilized because of a stroke. The nurse turns the patient and finds that the skin over the sacrum is very red and the patient does not feel sensation in the area. The patient has had fecal incontinence on and off for the last 2 days. The nurse identifies the nursing diagnosis of risk for impaired skin integrity. Which of the following goals are appropriate for the patient? (Select all that apply.)
A. Patient will be turned every 2 hours within 24 hours.
B. Patient will have normal bowel function within 72 hours.
C. Patient’s skin will remain intact through discharge.
D. Patient’s skin condition will improve by discharge.
B. Patient will have normal bowel function within 72 hours.
C. Patient’s skin will remain intact through discharge.
The skin remaining intact is an appropriate goal for the patient’s at-risk diagnosis. A return of normal bowel functioning is also appropriate since it indicates removal of a risk factor. Turning the patient is an intervention; skin condition improving by discharge is a poorly written goal that is not measurable.
DAR
Data
Action
Response
