NUR116 Lecture - Care Planning - Week 4

Question 1

What are the steps in Care Planning?

Answer 1

1- Assess: Collect and verify data.
2- Prioritize: what is most important for patient; use Maslow’s
3- Make a diagnosis: Make sure it fits, use NANDA, collaborate with patient
4- Plan outcomes: Goals; “What do you want to happen?”
5- Plan your interventions: What you will do to solve problem
6- Write your rationales: Evidence that interventions are scientifically based
7- Evaluate: Did pt reach goals? What worked/didn’t work?

Question 2

Nursing Diagnosis Parts and definitions

Answer 2

-Problem and its definition: What is the actual problem? What could happen (potential problem)?​

-Etiology​: Identify possible reasons for problem, list all etiologies and identify what is related to problem

-Symptoms/defining characteristics: what are signs/symptoms?

Question 3

7 Basic (RCC) Needs:

Answer 3

• Gaseous Transfer
• Body Defense
• Mobility
• Nutrition
• Elimination
• Psychological Regulation
• Chemical Regulation

Question 4

Types of Interventions

Answer 4

• Direct Care interventions - directly working with/in contact with client
• Indirect-care interventions
• Independent interventions: No medical order required
• Dependent interventions: Prescriptions, medical orders
• Collaborative/Interdependent interventions: Working with other professionals; involving other disciplines

Question 5

A nurse is caring for a patient who is incontinent of urine. What should the nurse do to prevent the patient from developing a skin breakdown?

a. Insert an indwelling urinary catheter.
b. Apply an absorbent brief.
c. Provide frequent skin care.
d. Alert the wound care nurse.

Answer 5

C. Provide frequent skin care

Rationale:
* Catheters should only be inserted for valid medical reasons; incontinence is not a valid reason
* Absorbent briefs can contribute to skin breakdown by keeping moisture on the skin.
* The wound care nurse would only be involved with patients who have actual wounds.

Question 6

What are sentinel events?

Answer 6

Never events
Things that should never happen, and cause severe harm to the patient

Question 7

A nurse is assessing the skin of a dark-skinned patient. What assessment should alert the nurse that there is a potential pressure
injury ? (select all that apply.)

pain to the sacral area
an area of hardened skin
area of darkened skin
localized edema
decreased moisture to the skin

Answer 7

an area of hardened skin
localized edema
pain to the sacral area
area of darkened skin

Question 8

What statement is true about mucosal membrane pressure injury?

a. They are staged the same as any other wound.
b. They are caused by excessive moisture.
c. They are caused by a buildup of eschar.
d. They cannot be staged.

Answer 8

D. These injuries cannot be staged, because mucosal tissue does not contain the same layers as the skin

Question 9

A patient has a Braden score of 23. How should the nurse interpret
this data?
a. low risk
b. no risk
c. severe risk
d. minimal risk

Answer 9

B. No risk
- A Braden score of 23 means there is no risk for developing a pressure ulcer
- Lowest score of 6 represents severest risk for developing a pressure ulcer

Question 10

What is our approach towards complimentary medicine?

Answer 10

• Protect patient from dangerous practice
• Permit harmless practice
• Promote/Use safe practice