Nursing Process

Question 1

What are the three types of nursing diagnosis currently recognized by the North American Diagnosis Association-International (NANDA-I)

Answer 1

1. Problem-focused nursing diagnosis
   A. A clinical judgement concerning an undesirable human response to a health condition/life process that exists in an individual, family, group or community
2. Risk nursing diagnosis
   A. A clinical judgment concerning the vulnerability of an individual, family, group, or community for developing an undesirable human response to a health condition/life process
3. Health promotion nursing diagnosis
   A. A clinical judgment concerning motivation and desire to increase well-being and to actualities human health potential. These responses are expressed by a readiness to enhance specific health behaviors and can be used in any health state. Health promotion responses may exist in an individual, family, group, or community

Question 2

What are the different types of nursing assessments

Answer 2

1. Initial assessment — performed on initial contact with the patient to identify normal functional status and collect data
2. Focused assessment— to determine specific problems identified during a previous or initial assessment
3. Time-lapsed reassessment— the nurse compares the patients current status to the baseline obtained previously and detects changes in all functional health patterns after an extended period of time has passed
4. Emergency assessment— the identification of a life-threatening situation that can occur any time a patient experiences a physical or psychological crisis

Question 3

What are the steps of the nursing assessment

Answer 3

1. Collecting data
2. Identifying cues (abnormal data) and making inferences
3. Validating (verifying) data
4. Clustering related data
5. Identifying patterns and testing first impressions
6. Reporting and recording data

Question 4

What are the steps in a physical assessment

Answer 4

1. Inspection —a concentrated watching. It is close, careful scrutiny, first of the individual as a whole and then each body system. During inspection, the patients anatomic structures are considered and any abnormalities are noted
2. Auscultation—listening to sounds produced by different structures of the body such as the heart and blood vessels, the lungs, and the abdomen. Certain sounds, such as congested breathing or bowel sounds can be heard without a special device, but most body sounds are very soft and must be channeled through a stethoscope
3. Palpation—follows and often confirms points noted during inspection. Palpation applies the sense of touch-via fingertips or the palm of the hand-to assess texture, temperature, moisture, consistency, organ location and size, fluid, and any swelling or masses. Light Palpation always precedes deep Palpation. Palpation always follows auscultation in the assessment of the abdomen, as to not disrupt bowel sounds
4. Percussion—employs the examiner’s sense of hearing to gather data. The examiner taps the patient’s skin with shorts sharp strokes to assess the underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size, and density of the underlying organ

Question 5

What are some significant auscultation findings when performing a GI assessment

Answer 5

1. Bruits—may indicate cardiovascular abnormality rather than GI pathology
2. High-pitched tinkles and peristaltic rushes—are audible when intestinal obstruction occurs
3. Decreased or absent bowel sounds—which can suggest paralytic ileus, gangrene, peritonitis, or inflammation

Question 6

What are potential lab tests ordered for a GI assessment

Answer 6

1. CBC: Hgb, HCT, differential leukocyte count
2. PT, PTT, INR
3. Electrolytes
4. Ketones and protein
5. Amylase
6. Lipase
7. Creatinine
8. Serum cholesterol
9. LDH, AST, ALT, ALP
10. Glucose
11. Bilirubin
12. Serum albumin
13. CPK
14. HBV, HCV
15. FOBT
16. Stool culture
17. FE, TIBC, Ferritin
18. Vitamin B12
19. Vitamin D
20. HP Breath/stool tests
21. Celiac panel
22. IBD panel
23. CEA, CA-19-9

Question 7

What are different types of imaging studies for a GI assessment

Answer 7

1. Type 1—simple Radiographic pictures in which structure are enhanced either by natural differences in radio density or by differences enhanced through instillation of a contrast agent
   A. Chest radiograph
   B. Flat plate of abdomen
   C. Upper GI series, may include Esophagogram or SBFT
   D. Lower GI series/barium enema
   E. Contrast radiographs
   F. Percutaneous transhepatic cholangiogram (PTC)
   G. Defecography
2. Type 2–a cross-sectional look at internal organs by sound waves, x-ray beams, or measurement of magnetic resonance signals
   A. Computed tomography —CT
   B. Ultrasonography
   C. Magnetic resonance imaging — MRI/MRCP
3. Type 3—pictures of internal organs detected by radioactive tracers and gamma cameras after the intravenous injection of a radioisotope
   A. Nuclear imaging scan.
   B. HIDA scan
   C. Gastric emptying scan
4. Endoscopic Exams
   A. EGD
   B. Colonoscopy
   C. Proctosigmoidoscopy
   D. Anoscopy
   E. ERCP
   F. EUS
   G. Single/double balloon enteroscopy
5. Test of gastrointestinal motility
   A. Manometry
6. Microscopic examination of tissue
   A. Liver biopsy
   B. Cytology
   C. Mucosal biopsy
7. Tests of digestive function
   A. Gastric analysis
   B. Fecal analysis
8. Misc. tests
   A.pH studies
   B. Bernstein test
   C. Virtual colonoscopy
   D. Video capsule
   E. PET scan
   F. Hydrogen breath test

Question 8

Examples of differences between nursing diagnosis and medical diagnosis

Answer 8

Nursing Diagnosis. Medical Diagnosis
1. Focus on care. Focus on etiology
2. Record the human response to actual or potential. Diagnoses a disease or medical condition
Health problems
3. Identifies patient problems and situations the nurse. Indicates a course of treatment the physician is licensed to treat
Is licensed to treat
4. Represents the intention that nurses will perform Constitutes the intention of prescribing specific treatments to
Interventions to alleviate, diminish, modify, or prevent. Cure the disease or reduce injury
A state of unwellness and maintain an optimal health state
5. May change from day to day as the patients’ s response. Remains the same as long as the disease persists
To therapy, health and illness change

Question 9

What are the steps to formulating a nursing diagnosis

Answer 9

1. Establish database by collecting information from the patient and/or family, reviewing the medical record, and assessing the patient
2. Analyze the data obtained by asking:
   A. Are there changes in the patient’s health status” (i.e. is the patient healthy or unhealthy)
   B. Does the patient’s medical record show values that deviate from the norm
   C. Is the patient physiologically healthy
   D. Is the patient psychologically healthy
   E. Is the patient sociologically healthy
   F. Is the patient spiritually healthy
3. Organize the date by summarizing the pattern of the problems discovered
   A. There is no problem, and intervention is unnecessary
   B. There is an actual or potential problem
   C. There is a clinical problem other than a nursing problem (a collaborative problem) that requires the nurse to consult with a sometimes cooperate with appropriate health care professionals
4. Chose a diagnostic label specific to the patient. Check your facility’s policy in the use of diagnostic labels. Most facilities use NANDA-I’s list
5. Identify the factors that appear to influence that patient, specific to the diagnostic label identified during the nursing assessment
6. List defining characteristics, which include signs, symptoms and other assessment findings
7. Confirm the sufficiency and accuracy of the database by evaluating the appropriateness of diagnoses to nursing interventions and ultimately determining that other qualified practitioners would arrive at same nursing diagnosis

Question 10

What are potential nursing diagnoses for gastroenterology patients

Answer 10

1. Nutritional metabolic pattern
   A. Body temperature, altered
   B. Dentition, altered
   C. Fluid volume deficit
   D. Growth and development delayed
   E. Infection, risk for
   F. Nutrition, altered; less than body requirements
   G. Nutrition, altered; potential for more than body requirements
   H. Obesity*
   I. Oral mucous membranes, altered
   J. Overweight*
   K. Skin integrity, impaired
   L. Swallowing, impaired
2. Elimination
   A. Bowel incontinence
   B. Constipation, chronic functional*
   C. Diarrhea
3. Activity-exercise pattern
   A. Activity intolerance
   B. Mobility, impaired physical
   C. Tissue perfusion, altered
4. Cognitive-perceptual pattern
   A. Knowledge deficit
   B. Sensory-perceptual alteration
5. Sleep-rest pattern
   A. Sleep pattern disturbance
6. Self-perception/self-concept pattern
   A. Anxiety
   B. Body image disturbance
   C. Fatigue
   D. Fear
   E. Hopelessness
   F. Powerlessness
   G. Self-concept disturbance
7. Role relationship pattern
   A. Communication, impaired
   B. Family process, altered
   C. Grieving
   D. Loneliness, risk of
   E. Role performance, altered
   F. Social isolation
   G. Social interaction, impaired
8. Sexuality pattern
   A. Sexual dysfunction
   B. Sexuality patterns, ineffective
9. Coping-stress tolerance pattern
   A. Adjustment,impaired
   B. Coping,ineffective
   C. Personal identity disturbed
   D. Powerlessness
   E. Self-concept-disturbed
   F. Self-esteem, disturbed

Question 11

What are the important reasons for developing a plan of care

Answer 11

1. A pan of care can identify patient problems that may be prevented, reduced, or resolved by nursing activities. It must be recognized that the nurse cannot solve all patient problems. Sometimes it is necessary for the nurse to seek assistance from other members of the healthcare team or the patient (or patient’s significant others)
2. A plan of action helps the gastroenterology nurse assign priorities for care and select nursing interventions or actions that meet the unique needs of the individual patient
3. A documented plan provides a means of communicating information that will help other members of the healthcare team provide continuity of care
4. The planning of care based on nursing diagnoses uses a universal language with which nurses can communicate about health problems, thus helping to build on the existing knowledge base of nursing science
5. The planning of care based on nursing diagnoses gives a professional quality and character, rather than merely vocational assistance, to the act of nursing. It serves to separate nursing and medicine, bringing the two professions into a collegial relationship in which nurses can demonstrate their unique knowledge base and contribute to their patients’ health

Question 12

What is the initial planning for an EVL procedure

Answer 12

1. Assessing supplies and equipment needed
   A. Flexible gastroscope
   B. Overtube with bite block
   C. Suction apparatus, including suction tip
   D. Positioning devices
   E. Ligation kit
   F. Topical anesthetic
   G. Sedative, depending on patient’s hemodynamic stability
   H. Devices for intra-procedure monitoring of vital signs
2. Checking the equipment for proper functioning
3. Verifying competency of staff performing the procedure

Question 13

What are planned nursing interventions to ensure that the patient will understand the purpose and expected outcomes of an endoscopic procedure

Answer 13

1. Allowing the patient to ask questions and verbalize any concerns
2. Supporting the patient by listening, showing concern, and encouraging questions
3. Being prompt when performing procedures to avoid delays or postponement
4. Involving family and significant others in discussions and questions about the procedure and care needed

Question 14

Typically, what activities encompass ongoing planning

Answer 14

1. Clarifying nursing diagnoses
2. Revising expected outcomes to make them more realistic and patient-centered
3. Developing new outcome statements and/or new diagnoses as indicated by analysis of new data
4. Identifying nursing actions that promote achievement of identified outcomes
5. Documenting patient responses to nursing interventions

Question 15

What are strategies that may help nurses to broaden their repertoire of nursing actions include

Answer 15

1. Consulting with successful colleagues and studying their successful practices
2. Researching the nursing literature for suggestions to improve care
3. Talking with patients and significant others about measures they have found most helpful in addressing their problems
4. Reviewing standards of care, including those of the American Nurses Association (ANA) and SGNA, professional guidelines, institutional standards, and accrediting agencies such as The Joint Commission or CMS

Question 16

What are requirements when writing nursing orders

Answer 16

1. Use directive verbs to describe clearly and concisely the action to be taken (i.e., what, where, who, when and how)
2. Date and sign the order, making a note when the plan is reviewed
3. Use only accepted abbreviations
4. Refer to policy manuals or other agency guidelines for routine steps for lengthy procedures

Question 17

What broad areas of nursing activity occur during implementation

Answer 17

1. The plan is put in motion
2. The data regarding patient care is updated as data collection continues
3. The nursing care and patient progress are documented and communicated

Question 18

What is required to carry out the plan of care

Answer 18

1. Cognitive ability—necessary to not only think crucially about a patient’s health problem but also apply nursing theories to solve problems and find appropriate solutions
2. Interpersonal skill—a component of overall professional skills. The ability to communicate clearly, competently, and compassionately helps elicit patient trust and cooperation. A nurse’s well-developed intellectual and interpersonal skills not only maximize the chance that healthy outcomes will be achieved by also ensure efficient implementation of care
3. Technical skill—necessary when a procedural intervention is required. Technical ability ranges from minimal to extensive, depending on the nature of equipment used to execute procedures and the complexity of the procedure

Question 19

Safety is the focus of many nursing activities carried out during implementation. Examples of typical nursing activities performed to safeguard patient safety include but are not limited to

Answer 19

1. Adhering to disinfection guidelines during reprocessing of contaminated equipment
2. Monitoring the environment for safety
3. Positioning the patient according to physiological principles during or after operative procedures to avoid neurovascular damage and skin breakdown
4. Verifying patient identification and informed consent
5. Routinely inspecting hospital equipment to ensure proper function

Question 20

There are some ways to free available time for implementing comprehensive nursing care which may include

Answer 20

1. Delegating technical and non-nursing tasks
2. Revising policies to delete obsolete and/or unnecessary practices

Question 21

Variables that influence how a plan of care is implemented fall into what six categories

Answer 21

1. Patient variables
2. Nurse variables
3. Standards of care
4. Research findings
5. Resources
6. Ethical and legal guides to practice

Question 22

What are the suggested guidelines for implementation of nursing care

Answer 22

1. Before instituting any measure to treat a health problem, the patient must be assessed to be sure action is still necessary
2. The nurse should be fully prepared to perform the planned action when her or she approaches the patient. All equipment should be ready, and the nurse should either know how to perform the nursing action or come with a nurse associate who does. The nurse should tell the patient who the action is being taken and what the potential adverse responses to the procedure are
3. The nurse should approach the patient with a caring attitude, using language the patient understands. By communicating genuine concern for what the patient is experiencing, the nurse conveys regard for the patient’s well-being
4. The nurse should develop a large repertoire of skilled nursing interventions. The larger an array of options he or she has to choose from when treating health problems, the greater the likelihood of success
5. The nursing actions chosen must comply with standards of care and be within the range of ethical and legal institutional guidelines to practice
6. The nurse should think critically about the plan really the best method of treatment. He or she should consult immediate colleagues, colleagues in related nursing fields, and relevant literature to discover more effective ways of managing health problems. The effectiveness of each action should be evaluated in terms of its positive and negative effects on outcome
7. The nurse should modify the prescribe interventions to accommodate the patient’s developmental and psychosocial circumstances, ability, and willingness to participate in achieving desired outcomes; the patient’s previous response to nursing measures; and any progress the patient has already made toward expected outcomes

Question 23

Data collection continues throughout the implementation phase, and is frequently updated. These activities serve three important functions during implementation by

Answer 23

1. Comparing new data against the baseline data to enable the nurse to identify patterns and trends in the patient’s health
2. Collecting data following nursing intervention to allow the nurse to evaluate the effectiveness of nursing actions according to evaluation criteria listed in the care plan
3. Revising the plan of care as the data is updated

Question 24

What are examples of the types of documentation for endoscopic procedures

Answer 24

1. Procedure performed
2. Date and time of the procedure
3. Equipment used
4. Staff present
5. Anesthesia and/or sedation administered and patient’s response
6. Medications and response
7. Vital signs and monitoring methods
8. Oxygen therapy used
9. Use of cautery, electrocoagulation, or laser
10. Dilators used
11. Solution injected
12. Specimens taken
13. Photographs, videos, and/or x-rays taken
14. Post-procedural diagnosis
15. Nursing notes and procedure nurse signature

Question 25

Nurses implement patient education through what areas of activity

Answer 25

1. Diagnosing and assessing a patient’s learning needs, learning style, learning capacity, knowledge deficit, and readiness to learn
2. Planning a learning activity
3. Providing learning opportunities
4. Evaluating learning

Question 26

Under what conditions can consent waived

Answer 26

1. Consent is not needed in an emergency if there is immediate threat to life or health; if experts agree that an emergency exists; and/or if the patient is unable to consent and a legally authorized person cannot be reached
2. Consent is not required for an action necessary to treat an unanticipated complication incurred during surgery when a legally authorized person cannot be reached

Question 27

Even when given, consent is legally valid only when all of the four following conditions are met

Answer 27

1. The physician and hospital make full disclosure concerning the proposed treatment or experiment
2. The patient possesses competent judgment and decision-making ability
3. The patient claims to comprehend the procedure, attending risks, and after-effects
4. The patient fives consent voluntarily of his or he own free will

Question 28

What are the three circumstances in which nurses may experience moral conflict when implementing a plan of care

Answer 28

1. Moral uncertainty, which is an inability to recognize the nature of an ethical problem
2. Moral dilemmas, as when a conflict arises between two or more ethical principle with no obvious solution
3. Moral distress, which is a conflict between an individual’s knowledge of ethically appropriate action and institutional constraints preventing action

Question 29

What are recommendations for the nurse’s role in ethics

Answer 29

1. All nurses advocate for human rights of patients, colleagues, and communities
2. Nurses advocate for the ethical and just practice of nursing by creating and sustaining environments that support accepted standards of professional practice, as the practice environment and rights of nurses influence the practice and moral context of nursing
3. Nurses strengthen practice environment by refusing to act in ways that would create a negative impact on the quality of care
4. Through their professional organization, nurses must reaffirm and strengthen nursing values and ideals with a united voice that interprets and explains the role of nursing in society
5. Health care agencies pay close attention to the potential for human rights violations as they relate to patients, nurses, health care workers, and others within their institutions
6. Nurses must examine the conflicts arising between their own personal and professional values and the values and interests of others who are also responsible for patient care and health care decisions, and they must address these conflicts in ways that ensure patient safety and promote the best interests of the patient

Question 30

The process of evaluation is the analysis of the patient’s progress toward the attainment of preset outcomes (goals). What does the ANA state more specifically

Answer 30

1. Evaluation is systemic, ongoing, and criterion-based
2. The patient, significant others, and other healthcare providers are involved in the evaluation process as appropriate
3. Ongoing assessment data are used to revise diagnoses and outcomes, modifying the plan of care as needed
4. Revision in diagnoses, outcomes, and the plan of care are documented
5. The effectiveness of the interventions is evaluated in relation to outcomes. Documentation of the patient’s progress toward achievable outcomes is retrievable
6. The patient’s responses to interventions are documented
7. The nurse acts as the patient’s advocate

Question 31

What are important points to remember when reassessing a patient for satisfactory goal resolution include

Answer 31

1. Does the patient have the ability to achieve the goals set? Are the goals realistic?
2. Canon the patient realistically manage the totality of the activities of daily living (ADL) upon discharge, or does his or her physical or emotional state make this an unattainable goal
3. Was the patient involved in establishing the goals

Question 32

More than the patient’s healthcare status must be taken into account in the predetermination of patient goals and outcomes. What are some of those factors

Answer 32

1. Past and present coping mechanism
2. Spiritual beliefs
3. Support systems available at the current time and in the future
4. Cultural influences
5. Current level of activity and future activity expectations
6. Disease process and treatment impact on self-image, comfort level, and ability to function independently