NURSING PROCESS: 6 STEPS

Question 1

• is a scientific process which is a foundation, the essential tool, and the enduring skill that has characterized nursing from the beginning of the profession.

Answer 1

Nursing Process

Question 2

• It is a plan of care for the patient which may look different from different institutions but provides both systematic and effective course of intervention to patients.

Answer 2

Nursing Process

Question 3

• Data collection to establish DATABASE

Answer 3

ASSESSMENT

Question 4

According to _, Assessing is the systematic and continuous collection, organization, validation, and documentation of data.

Answer 4

Kozier

Question 5

ASSESSMENT

Purpose:

Answer 5

• To gather data, for database, for health, diseases
• Make a judgement about the patient’s health status, ability to manage his/her own health care and need for nursing
• Plan individualized holistic care that draws on a patient’s strength

Question 6

ASSESSMENT

Activities:

Answer 6

• Establish a database
• Obtain a nursing health history
• Conduct Physical Assessment
• Review of patient records
• Review of nursing literature
• Consultation of support persons
• Consultation of health professionals.

Question 7

TYPES OF ASSESSMENT

Answer 7

Initial Assessment
Problem-Focused Assessment
Emergency Assessment
Time-lapsed Assessment

Question 8

TYPES OF ASSESSMENT

• Performed shortly after being admitted

Answer 8

Initial Assessment

Question 9

TYPES OF ASSESSMENT

• Gather data about the problem that has been identified

Answer 9

Problem-Focused Assessment

Question 10

TYPES OF ASSESSMENT

• Perform when physiologic/psychologic crisis present to identify life-threatening problem

Answer 10

Emergency Assessment

Question 11

COMPONENTS OF ASSESSMENT

Answer 11

Data Collection
Data Validation
Data Organization
Communication of Data (Taylor)
Documentation of Data

Question 12

COMPONENTS OF ASSESSMENT

• it includes health history and current problems

Answer 12

Data Collection

Question 13

Consideration and Preparing Data Collection:

Answer 13

o Establishing assessment priorities
(influenced by: health orientation,
developmental stage, need for nursing)
o Practical considerations
o Structuring data collection

Question 14

TYPES OF DATA

Answer 14

Subjective and Objective Data

Question 15

• Information perceived only by the client or by the affected person cannot be perceived or verified by another person.
• Also called __ or __

Answer 15

Subjective Data
symptoms or covert data

Question 16

• observable and measurable data that can be seen, heard, smelled or felt by someone other than the person experiencing them
• Also called __ or __

Answer 16

Objective Data
signs and overt data

Question 17

SOURCES OF DATA

Answer 17

Client/Patient
Support people like family members,
Client or Patient Record

Question 18

CHARACTERISTICS OF DATA

Answer 18

Complete
Factual and Accurate
Relevant

Question 19

COMPONENTS OF DATA COLLECTION

Answer 19

NURSING HISTORY
composed of:
• PROFILE: name, age, sex, marital status, religion, occupation, education
• Reason for seeking health care
• Normal health habits and patterns and related needs for nursing assistance
• Cultural consideration in relation to diet, decision making and activities
• Current state of health, functioning of body system degree of pain and past medical and surgical history
• Current medication allergies and record of immunizations and exposure to communicable diseases
• Perception of health status and the meaning, the patient attributes to health and illness, and characteristics response or coping patterns
• Developmental history, family history, environmental history and psychosocial history
• Patient’s and family expectations of nursing and health care team
• Patient’s and family’s educational needs and ability and willingness to learn
• Patient’s and family’s ability and willingness to participate in plan of care
• Whether or not an advance directive exists or if the patient wants to help to prepare an advance directive patient’s personal resource (strength) deficit
• Patient’s potential for injury

Question 20

METHODS OF COLLECTION INFORMATION

Answer 20

Observation
Interview
Examination
Medical Record Review

Question 21

METHODS OF COLLECTION INFORMATION

• to gather data by using senses (smell, hearing, touch, sight)

Answer 21

Observation

Question 22

METHODS OF COLLECTION INFORMATION

• is a planned communication or conservation

Answer 22

Interview

Question 23

METHODS OF COLLECTION INFORMATION

• Final activity of data collection

Answer 23

Medical Record Review

Question 24

STAGES OF INTERVIEW

Answer 24

Preparatory Stage
Introduction Stage
Working Phase/ The Body of Interview
Termination/ Closing Stage

Question 25

STAGES OF INTERVIEW

• read past and current
records and report
when available
• Should provide privacy
for the patient (– room)
• Nurse and patient
distance (3-4 feet apart)
to facilitate easy
exchange
• Length of interview (10-
15 mins)

Answer 25

Preparatory Stage

Question 26

STAGES OF INTERVIEW

• Establish rapport –
understanding
• Orientation – until when,
duty time,
• Crucial because it sets
the tone for nurse-
patient interaction

Answer 26

Introduction Stage

Question 27

STAGES OF INTERVIEW

• Nurse gathers all
information needed to
form the subjective
database

Answer 27

Working Phase/ The body of the interview

Question 28

STAGES OF INTERVIEW

• Patient should be
advised that the
interaction is coming to
an end

Answer 28

Termination/ Closing

Question 29

APPROACHES TO INTERVIEW

Answer 29

Directive Interview
Non-Directive/ Rapport Building Interview

Question 30

APPROACHES TO INTERVIEW

• highly structured interview

Answer 30

Directive Interview

Question 31

APPROACHES TO INTERVIEW

• Allows the client to control the purpose, subject
matter and pacing
• RAPPORT – understanding between 2 or more
people

Answer 31

Non-Directive/ Rapport Building Interview

Question 32

TYPES OF INTERVIEWS

Answer 32

Closed Questions
Open-ended Question
Neutral Question
A Leading Question

Question 33

INTERVIEW CAN BE AFFECTED BY:

Answer 33

Time
Place
Seating Arrangement
Distance/Proxemics
Language

Question 34

EXAMINATION

Purpose:

Answer 34

• Appraisal of health status
• Identification of history problems

Question 35

METHODS OF PHYSICAL EXAMINATION

Answer 35

Inspection
Palpation
Percussion
Auscultation

Question 36

MEDICAL RECORD REVIEW

Purpose:

Answer 36

• Identify what medications the patient is taking
• To understand the interdisciplinary care of planning
• To understand the nursing diagnosis and intervention
• To determine the presence and content of advance directives

Question 37

DATA VALIDATION

Purpose:

Answer 37

To keep the data free from error, bias and possible misinterpretation

Question 38

IMPORTANCE OF VALIDATING DATA

Answer 38

• ensures that assessment information is complete
• ensures objective ones related subjective agree
• obtain additional information that may have been over looked
• differentiate between

Question 39

• are subjective or objective data that can be directly observe by the nurse: that is the client says or what the nurse can see, hear, feel, smells, or measures.
• Baseline data as a result of assessment phase of the nursing process

Answer 39

CUES

Question 40

• Nurse’s interpretation or conclusion made or based on the cues
• Write conclusion/inference as is

Answer 40

Inferences

Question 41

INFERENCES MAY BE VALIDATED IN MULTIPLE WAYS

Answer 41

• Physical examination using proper equipment and process
• Clarifying statement
• Sharing inferences with other respected members of the team

Question 42

DATA ORGANIZATION

• The nurse usses a written format that organized the assessment data systematically. This often referred as:

Answer 42

Nursing health history
Nursing assessment
Nursing database form

Question 43

DATA ORGANIZATION

• Some of the Nursing Conceptual Model

Answer 43

Roy’s Adaptation Model
Wellness Model
Henderson’s Component of Nursing

Question 44

• Pivotal second phase (Analyzing &
Synthesizing)
• In this phase nurses use critical thinking skills to interpret/analyze assessment data and identify client strength and health problems
• All activities proceeding this is directed towards formulating nursing ____.

Answer 44

DIAGNOSING

Question 45

• refers to the reasoning process, whereas the term DIAGNOSIS is a statement or conclusion regarding the nature of the phenomenon.

Answer 45

DIAGNOSING

Question 46

• The standard NANDA name for the diagnosis are called ____
.
• And the client problem statement consisting the diagnosis, the diagnostic label (+) etiology (causal relationship between a problem and its related or risk factor) is called ____.

Answer 46

DIAGNOSTIC LABELS

NURSING DIAGNOSIS

Question 47

1990 (NANDA)

Answer 47

• clinical judgement about the individual, family or community responses to actual and potential health problems / life processes.
• It provides the bases for selection of nursing interventions to achieve outcomes for which the nurse is accountable. It implies the following:
o Professional nurses (RN) are responsible for making nursing diagnoses even though other health team may contribute to the process and may implement nursing care.

• The domain of nursing diagnosis includes only those health states that nurses are educated and licensed to treat (nurses are not educated to diagnosis and treat diseases)
• A nursing diagnosis is a judgment made only after thorough, systematic data collections.
• Nursing diagnosis describe a continuum of health states:
o deviation from health, presence of risk & factors and areas of enhanced personal growth
o Analysis of patient data to identify patient strength and health problems that independent nursing intervention can prevent or resolve.

Question 48

• are actual or potential health problems that can be prevented or resolved by independent nursing intervention.

Answer 48

NURSING DIAGNOSIS

Question 49

• a specific result of diagnosing and is the problem statement that the nurse makes regarding a patient’s condition.

Answer 49

NURSING DIAGNOSIS

Question 50

(ANA) clinical judgment about a patient’s response to actual or potential health conditions or needs.

Answer 50

NURSING DIAGNOSIS

Question 51

NURSING DIAGNOSIS

PURPOSE:

Answer 51

• to identify client strength and health problems that can be prevented or resolved by collaborative and independent nursing.
• To develop a list of nursing and collaborative problems.
• To identify how an individual, groups or community responds to actual or potential health and life processes,
• Identify factors that contribute to a cause of health problems (etiology)
• Identify resources or strengths the individual, group or community can draw on, to prevent or resolve problems,

Question 52

• It is a condition that necessitates intervention to prevent/resolve disease or illness or to promote coping wellness.

Answer 52

HEALTH PROBLEM

o Memorize: hemoglobin, blood pressure, vital signs, standards, of certain age groups

Question 53

NURSING DIAGNOSIS

ACTIVITIES:

Answer 53

1. Interpret and analyze patient data.
   o Compare data against standards/
   o Cluster or group data (generate tentative hypotheses)
   o Identify gaps and inconsistencies
2. Determine client’s strengths, health problems, risk and diagnosis (problem identification).
3. Formulate and validate nursing diagnoses and collaborative problem statements.
4. Develop prioritized list of nursing diagnoses.
5. Document nursing diagnosis in the care plan.

Question 54

TYPES OF NURSING DIAGNOSIS

Answer 54

Actual Nursing Diagnosis
Risk Nursing Diagnosis
Wellness Nursing Diagnosis
Possible/Tentative Nursing Diagnosis
Syndrome Nursing Diagnosis

Question 55

TYPES OF NURSING DIAGNOSIS

• A client problem that is present at the time of the nursing assessment

Answer 55

Actual Nursing Diagnosis

o Example: ineffective breathing pattern, anxiety
o P + E + S = actual nursing diagnosis

Question 56

TYPES OF NURSING DIAGNOSIS

• a clinical judgment that problem does not exist, but the presence of risk factors indicate that a problem is likely to develop unless nurses intervene.

Answer 56

Risk Nursing Diagnosis

• All people admitted to a hospital have possibility of acquiring infection but a patient with DM or compromised immune system are risk or acquiring infection.
o Example: Risk for infection
o P + E (eliminate signs and symptoms) = risk nursing diagnosis

Question 57

TYPES OF NURSING DIAGNOSIS

• Describe human responses to levels of wellness in an individual, family or community that have a readiness for enhancement.

Answer 57

Wellness Nursing Diagnosis

Question 58

WELLNESS NURSING DIAGNOSIS

• 2 cues must be present for valid wellness diagnosis:

Answer 58

o a desire for a high level of wellness
o an effective, present status or function

o Example: Readiness for enhanced family coping

Question 59

TYPES OF NURSING DIAGNOSIS

• While not an official type of nursing diagnosis, ___ applies to problems suspected to arise.
• This occurs when risk factors are present and require additional information to diagnose a potential problem.

Answer 59

Possible/Tentative Nursing Diagnosis

Example:
o Possible sensory-perceptual alteration
o Possible nutritional deficit
o Possible social isolation R/T unknown etiology.

Question 60

TYPES OF NURSING DIAGNOSIS

• A clinical judgment describing a specific cluster of nursing diagnoses that occur together, and are best addressed together and through similar interventions.

Answer 60

Syndrome Diagnosis

Example:
Risk for disuse syndrome (cluster of diagnosis associated with this syndrome includes):
o Impaired physical mobility
o Risk for impaired tissue integrity
o Risk for activity intolerance
o Risk for constipation.
o Risk for injury risk for powerlessness
o Impaired gas exchange

Question 61

COMPONENTS OF A NANDA NURSING DIAGNOSIS:

Answer 61

P + E + S
1. The problem and its definition (P)
2. The Etiology (E)
3. The defining characteristics (S–signs and symptoms)

Question 62

• Describes the client’s health problem, state or response for which nursing therapy is given.
• It describes the client’s health status clearly or concisely in a few words.

Answer 62

Problem(Diagnostic Label)

Question 63

PROBLEM (DIAGNOSTIC LABEL)

Purpose:

Answer 63

• To direct the formation of client’s goals and desired outcomes.
• It may also suggest some nursing interventions.
(It must be specific and should follow a NANDA label).
Example:
o Deficient knowledge (Medication – emphasize the kulang) or
o Deficient knowledge (Dietary Adjustment)

Question 64

• words that have been added to some NANDA labels to give additional meaning to the diagnostic statement.

Answer 64

Qualifiers

Question 65

Example of QUALIFIERS:

Answer 65

• DEFICIENT - inadequate in amount, quantity, or degree not sufficient: incomplete
• IMPAIRED - made worse, weakened, damaged, reduced, deteriorated
• DECREASED - lesser in size, amount or degree
• INEFFECTIVE - not producing the desired effect
• COMPROMISED - to make vulnerable to threat

Question 66

• related factors and risk factors
• identifies one or more probable causes of the health problem, give direction to the required nursing therapy and enables the nurse to individualize the client’s care,

Answer 66

Etiology

o Activity intolerance R/T generalized
weakness (P+ E)

Question 67

• the clusters of signs and symptoms that indicated the Object & Subject data the signal the existence of actual and potential presence of a particular diagnostic label.

Answer 67

Defining Characteristics

Question 68

DEFINING CHARACTERISTICS

PHRASES:

Answer 68

o Sign/symptom + Related to (R/T) + specific probable cause
o Secondary to + Medical diagnosis
o As manifested by + “verbalization of the patient” “observation”

Question 69

DEFINING CHARACTERISTICS

FOR ACTUAL NURSING DIAGNOSIS

Answer 69

• defining characteristics are the client’s signs and symptoms.

Question 70

DEFINING CHARACTERISTICS

FOR RISK NURSING DIAGNOSIS

Answer 70

• no subjective and objective signs are present.
• Thus the factor that causes the client to be more than “normally” vulnerable to the problem form the etiology of a risk nursing diagnosis.

Question 71

REMEMBER THE FOLLOWING GUIDELINES

• to ensure that your Diagnostic statement are correctly written:

Answer 71

1. Phrase the nursing diagnosis as a patient problem or alteration in health statement rather than the patient need.
2. Check to make sure that the patient problem proceeds the etiology and that the two are limited by the phrase “Related to.”
3. Defining characteristics, when included in the nursing diagnosis, should follow. the etiology and be linked by the phrase as manifested by or evidenced by.
4. Write in legally advisable term.
5. Use non-judgmental language. validation
6. Be sure the problem statement indicates what is unhealthy about the patient or what the patient wants to change (enhance).
7. Avoid using defining characteristic, medical diagnoses, or something that cannot be changed in the problem statement.
8. Reread the diagnosis to make sure the problem statement suggests patient outcomes and that etiology will direct the selection of nursing measures.
9. Disease process

Question 72

DIFFERENCE BETWEEN NURSING DIAGNOSIS AND MEDICAL DIAGNOSIS

NURSING DIAGNOSIS:

Answer 72

• Is a statement of nursing judgment referred to a condition that nurses are licensed to treat
• Describe a client’s physical, socio-cultural, psychological, and spiritual responses to an illness or health problems.
• Nursing diagnosis changes as the client’s response change.
• Focus on unhealthy responses to health and illness
• Describe problems treated by nurses within the scope of independent nursing practice.

Question 73

DIFFERENCE BETWEEN NURSING DIAGNOSIS AND MEDICAL DIAGNOSIS

MEDICAL DIAGNOSIS:

Answer 73

• Is made by a physician and refers to a condition that only a physician can treat.
• It refers to the disease processes
o specific pathophysiologic responses that are fairly uniform from one client to another.
• Remains the same for as long as the disease process in present.
• Identify diseases
• Describe problems for which the physician directs the primary treatment.

Question 74

THE DIAGNOSTIC PROCESS

Answer 74

1. Analyzing Data
2. Identifying Health Problems and Risks and Strength (Focus Area)
3. Formulating Diagnostic Statements

Question 75

THE DIAGNOSTIC PROCESS

• a process of determining the relatedness of facts and determining whether any patterns are present, whether and patterns represent isolated incident, whether the data are significant.
• Compare data against standard/norm
o is generally accepted measure, rule, model or pattern (identify significant cues)

• Cluster cues (generate tentative hypothesis)
• Identify gaps and inconsistencies.

Answer 75

1. ANALYZING DATA

Question 76

THE DIAGNOSTIC PROCESS

2. IDENTIFYING HEALTH PROBLEMS AND RISKS AND STRENGTH (FOCUS AREA)

Answer 76

• Determine problems and risks
• Determine strengths

Question 77

THE DIAGNOSTIC PROCESS

3. FORMULATING DIAGNOSTIC STATEMENTS

Answer 77

Basic Two-Part Statement
Basic Three-Part Statement
One-Part Statement

Question 78

VALIDATE NURSING DIAGNOSIS

Answer 78

• With the patient, family and other health care providers when possible and appropriate

Question 79

PROMPTS FOR CRITICAL THINKING DURING DIAGNOSIS

Answer 79

• What do the data mean? How do you know?
• Are your assessment date accurate?
• Complete? Are you sure?
• How are these similar/different? How are you clustering them
• What assumption or biases do you have in this situation?
• Is your diagnosis/etiology supported by enough data?
• Does the patient see this as a problem? The family? Other health care providers?
• Is this a nursing problem or collaborative problem? Should you talk to other nurses about this problem or speak with the doctor?
• Have you missed any other problem because you focused only on the obvious one?
• Did you include patient and family strengths, resources, and deficits in your thinking?
• HOLISTIC

Question 80

VARIATIONS AND FORMATS:

Answer 80

• Writing unknown etiology when the defining characteristics are present but the nurse does not know the cause or contributing factors.
• Using the phrase complex there are too many etiologic factors or when there are too many complex states in brief phrases.
• Using the word possible to describe either the problem or the etiology.
• When the nurse believes more data are needed about the client’s problem or the etiology, the word possible is inserted.
• Using Secondary to, to divide etiology, into past, thereby making the statement more descriptive and useful.
• The part following secondary to is often pathophysiologic or disease process.
• Adding a second part to the general response to NANDA label to make it more precise.
• It is allowed to write “unknown etiology”
• Using COMPLEX when too many
• Use POSSIBLE if not sure
• SECONDARY TO

Question 81

IMPORTANCE OF WRITING ETIOLOGY

Answer 81

• It clarifies the problem
• It can be concisely stated
• It helps suggest nursing action

Question 82

AVOIDING ERROR IN DIAGNOSTIC REASONING

Answer 82

• Verify
• Have a working knowledge on what is normal
• Build a good knowledge on what is normal
• Consult resources
• Base diagnosis on patterns
• Improve critical thinking in skill

Question 83

o The nurse develops, outcomes for the patient to achieve showing an optimum or improved level of functioning in the problem areas identified in the nursing diagnoses.

Answer 83

OUTCOME IDENTIFICATION

Question 84

• The nurse analyzes the strength and
weaknesses of the patient. The patient’s family the nursing personnel, the healthcare facility and available resources (including other health care professional)
• The nurse also examines her own strength, beliefs, and values that might affect outcome identification

Answer 84

OUTCOME IDENTIFICATION

Question 85

OUTCOME IDENTIFICATION

• The resulting outcomes and plan of nursing care are designed to help the patients and their family:

Answer 85

o make informed decisions about their health and functioning
o maintain their current level of health and functioning if they are identified as being at risk for developing problems
o Avoid injury or disease
o Regain a previous level of health and functioning
o Reached an improved level of health and functioning
o Adjust to a reduced level of health and functioning when improvement is not possible
o Adapt to a progressive level of functioning
o Experience a peaceful death

Question 86

OUTCOME IDENTIFICATION =

Answer 86

SETTING PRIORITES + ESTABLISHING OUTCOMES

Question 87

• Ordering the delivery of nursing care so that more important or life threatening problems are treated before the less critical

Answer 87

Setting Priorities

o High – deserves immediate nursing
attention for plan of treatment
o Middle
o Low

Question 88

GUIDELINES FOR SETTING PRIORITIES

Answer 88

• Maslow’s hierarchy of needs
• Focus on the problems the patient feels most important
• Consider the patient’s culture, values, beliefs when setting priorities
• Consider the effect of potential problems when setting priorities (prevention of high problem, rather than treatment of the problems when it is developed).
• Consider cost resources available, personnel and time needed to plan
• Consider state laws, hospital policy statement and outcome criteria establishing for the particular setting

Question 89

ESTABLISHING OUTCOMES

AN OUTCOME
PATIENT OUTCOME

Answer 89

AN OUTCOME
• is a measurable, expected client goal (ANA 1988)
• To be achieved at some specific time in the future

PATIENT OUTCOME
• The desired result of nursing care
• That which you hope to achieve with your patient and which is designed to prevent, remedy, lessen the problem identified in the nursing diagnosis

Question 90

WHY IS OUTCOME IDENTIFICATION NEEDED?

Answer 90

• It gives guidance in the selection of nursing interventions
• They are constant future targets to remind all caregivers and the patient why certain action or interventions are done
• Gives sense of where this particular patient started from and where the individual and the nurse hope to end up
• Outcome will be the criteria and to evaluate the success of nursing interventions
• It helps motivate the nurse, the patient and the family to continue their efforts.

Question 91

COMPONENTS OF A STATEMENT

Answer 91

Outcome statement = patient behavior (verb) + criteria of performance + condition (if needed) /modifier + time frame

Question 92

COMPONENTS OF STATEMENT

• Observable (it can be seen, heard, felt or measured by the nurse or reported by the patient).

Answer 92

Patient Behavior/Verb

Question 93

A. PATIENT BEHAVIOR/VERB

FOR RISK NURSING DIAGNOSIS:

Answer 93

• The activity selected which reflect maintenance of current status or level of functioning.
• The outcome should not deal w/ etiology but should address a lessening or elimination of the problem

Question 94

COMPONENTS OF STATEMENT

• A stated level or standard for the
patient behavior stated in the outcome

Answer 94

B. Criterion of Performance

Question 95

Criterion of Performance

• The level at which the pt will perform the behavior
• How will? How Far? How much?

Answer 95

Criterion of Acceptable Performance

Question 96

COMPONENTS OF STATEMENT

• Can be thought as specific aids that will help the patient perform a behavior at the time specified in the criteria performance of the outcome statement

Answer 96

Conditions

• Not all outcome will have conditions

Question 97

COMPONENTS OF STATEMENT

• The outcome statement includes a time/date to clarify how long it would realistically take for the patient to reach the level of functioning stated in the criteria part of the outcome
• Stated in minutes, hours, weeks, or months

Answer 97

D. Time Frame

Question 98

Types of Outcome

Answer 98

Intermediate Outcome
Long Term/Final Outcome
Discharge Outcome
Health Promotion/Wellness Outcome

Question 99

TYPES OF OUTCOME

• Identify behavior a patient can achieve easily or quickly

Answer 99

Intermediate Outcome

Ex:
o Reestablishment of urinary elimination within 6 hours of surgery
o Respiration below 30 breath per minute within 1 hour
• Return bowel round within 12 hours post OP

Question 100

INTERMEDIATE OUTCOME

Ex.
o Weight of 210 lbs. by Feb 7
o Weight of 210 lbs. by Feb 14
o Weight of 210 lbs. by Feb 21
OR
o Week of 10/10: feed self by the end of the week
o Week 10/17: brushes teeth at the end of the week (personal hygiene)

Answer 100

Progressive Intermediate Outcome

Question 101

TYPES OF OUTCOME

• Gives the direction for nursing care over time
• This can be thought of an eventual destination
• Is a series of stops on the way to final destination
• Like a cross country trip

Answer 101

Long Term/Final Outcome

EX:
• Reestablishment of patient usual bowel elimination pattern within 2 months
• Reestablishment of normal voiding patterns by 5 days post-OP (catheter, bladder training)
• Self-care of colostomy 1 month after surgery
• Patient state no longer afraid of sever pain during terminal illness from cancer after 1 week on IV morphine.

Question 102

LONG TERM/FINAL OUTCOME

Considerations:

Answer 102

• Prognosis of the patient health problem
• Resources available
• Strength and weaknesses of the patient (pt/fx)
• Nursing care abilities of the personnel who will be working with the patient

Question 103

TYPES OF OUTCOME

• Often appear at the end in critical pathways used with the hospitalized patient
• These outcomes identify the behavior the patient is expected to achieve to be safely discharge from institution.

Answer 103

Discharge Outcomes

EX:
• After a total knee replacement, states that pain management is acceptable on oral analgesic not IV
• Low impact exercise
• Walk for 50 feet demonstrating correct technique for crutch care or walking
• No signs (sn/sx) or symptoms of wound infection/delayed healing at infection size.
• Some outcomes are designed to maintain level of functioning during the time the patient is receiving care
EX:
• Pt to report that pain is controlled at an acceptable level during hospitalization
• Even within the hospital, _ such as post anesthesia and _ often time discharge outcome for acute-care areas
EX:
• Spontaneous respiration in the normal adult range (normal RR: 12-16)

Question 104

TYPES OF OUTCOME

Example:
• Physical well-being: freedom from injury, illness and disease
• Active movement in life, physically, mentally, and emotionally from birth to death
• Psychosocial well-being: strong, self-esteem and social support system
• Balance of life roles: personal, family, career
• Reports feeling healthy, useful and happy in all growth and developmental stages (neonatal, infancy, etc.)
• Stress should be low with life satisfaction rating high

Answer 104

Health Promotion/Wellness Outcome

Question 105

GUIDELINES FOR WRITING OUTCOME IDENTIFICATION

Answer 105

FOR ACTUAL NURSING DIAGNOSIS
1. the outcome is a patient behavior that demonstrate reduction or alleviation at the problem
FOR RISK NURSING DIAGNOSIS
2. The outcome is a patient behavior that demonstrate maintenance of the current status of health or function

3. The outcome is realistic for the patients _ in the time space you designate in your outcome
4. The outcome is realistic for the nurse’s level of skills, experience and time/_
5. The outcome is congruent with and supportive
   of other therapies
6. Whenever _ of the outcome is important and
   valued
7. The outcome is observable or measurable pt behavior (hear, smell, feel, measured the patient’s response and avoid words such as good, normal, adequate and improved –
   general objectives)
8. Write outcomes in terms of patient behavior not nursing actions
9. Keep the outcome short
10. Make the outcome specific
11. Device level outcomes from only one nursing dx
12. Designate a specific time for the achievement of
    each outcome

Question 106

• The nurse develops a plan of care that prescribes interventions to attain expected outcomes.

Answer 106

Planning

Question 107

_____ are specific activities that
the nurse plans and implement to help a patient achieve identified outcome - the patient will reduce to eliminate the diagnosed problems.

Answer 107

Nursing Interventions

Question 108

PLANNING/ Nursing Interventions

Also called:

Answer 108

o Nursing Actions, Nursing Strategies, Nursing Treatment Plans, and Nursing Orders

Question 109

PLANNING

Interventions should be identified:

Answer 109

• What to be done
• When the activity is to be done and how often
• The derivation of each intervention when appropriate
• Any preceding or follow-up activities
• The date of interventions were(?) selected
• The sequence in which nursing action are to be performed when one action is dependent on or facilitated by a previous action
• Signed/ _

Question 110

TYPES OF NURSING INTERVENTIONS

Answer 110

1. Environmental Management
2. Physician - Initiated and Ordered Interventions
3. Nurse - Initiated and Physician Ordered Interventions
4. Nurse - Initiated and Ordered Interventions

Question 111

TYPES OF NURSING INTERVENTIONS

• Establishing and maintaining safe environment

Answer 111

Environmental Management

Question 112

TYPES OF NURSING INTERVENTIONS

• Ex: IV Fluid or antibiotics

Answer 112

PHYSICIAN-INITIATED AND ORDERED
INTERVENTION

Question 113

TYPES OF NURSING INTERVENTIONS

Ex: prn (paracetamol) orders, analgesic

Answer 113

NURSE-INITIATED AND PHYSICAN ORDERED INTERVENTIONS

Question 114

TYPES OF NURSING INTERVENTIONS

• Interventions solely in the range of professional nursing

Answer 114

NURSE-INITIATED AND ORDERED

Question 115

NURSE-INITIATED AND ORDERED

• Within this category are several forms of individual nursing interventions

Answer 115

1. Health teaching and promotion
2. Consistency to help _
3. Referrals to other nurses or health care professionals;
4. Specific nursing treatments to prevent problems or lessen amount(?) difference such as repositioning, functioning, dressing wound, ROM exercise, etc.
5. Provide supports, comfort and
   encouragement
6. Assessment of patient status or _ treatments ordered by nurses, physicians, other health professionals
7. Discharge (?) planning, related to lifestyle changes, coping with health changes and medical treatments, setting priorities. (EX: DM through exercise and diet)
8. Assistance with meeting basic needs/ADL and ensuring safety

Question 116

• Nursing actions are based on principles and knowledge integrated from previous nursing education and experienced

Answer 116

RATIONALE FOR NURSING INTERVENTIONS

Question 117

SUGGESTION IN SELECTING NURSING INTERVENTIONS

Answer 117

1. Review nursing dx so that the problem and etiology are clear
   o For risk nursing dx, select interventions to minimize or eliminate risk factors
   o Ex: insulin dependent diabetics are at risk for tissue damage in the legs and feet
   o Hence, teaching good foot care and maintenance of blood glucose level as close to normal
2. Examine the intermediate and final outcomes so that you know where you are going and know the step to get there
3. Consider all possible nursing actions that might help the patient achieve the outcome:
   o Changes in the environment
   o Activity for the patient and the family to perform independently
   o Activities to perform with the patient
   o Activities to perform for the patient
   o Ass. Of other healthcare professionals
   o Involvement of the patient’s friends and family
   o Change in the nurse (increase knowledge and skills)
4. Use standard care plan and critical clinical pathways as guideline for developing and planning a patient’s nursing care
5. Use the patient and the family as source of possible nursing intervention
6. Use resources such as nursing books
7. Consider dis/advantages of possible nursing interventions and select those that meet the following criteria:
   o Nursing action must be safe for the patient
   o Nursing action must be congruent
   o Nursing actions selected are most likely to develop the behavior described in the outcome
   o Nursing actions are realistic
   o Nursing actions consider meeting lower-level
   survival needs before high level needs

Question 118

NURSING INTERVENTION IS DIVIDED INTO 6 DOMAINS

Answer 118

Physiological: Basic
Physiological: Complex
Behavior
Safety
Family
Health Care System

Question 119

6 Domains

Physical functioning

Answer 119

PHYSIOLOGICAL:
BASIC

Question 120

6 DOMAINS

Balance or homeostatic

Answer 120

Physiological: Complex

Question 121

6 DOMAINS

Care that supports psychological
functioning and lifestyle changes

Answer 121

Behavior

Question 122

6 Domains

Care that supports protection against harm

Answer 122

Safety

Question 123

6 Domains

Care that promotes the family unit

Answer 123

Family

Question 124

6 Domains

Care that supports the efficient use of available health care system

Answer 124

Healthcare System

Question 125

CRITERIA OF CHOOSING NURSING INTERVENTIONS

Answer 125

• Safe and appropriate for the individual’s age, health and condition
• Congruent with the client’s values, beliefs, and culture
• Congruent with other therapies
• Based on knowledge and experience on knowledge from relevant sciences
• Within established nursing standards of care as determined by state laws, professionally associated and the policies of institution.

Question 126

Writing Nursing Orders

Answer 126

Date
Action Verb
Content Area
Time
Signature

Question 127

• It is the fifth phase in the nursing process and is consists of validating the care plan, documenting the care plan, giving and documenting the nursing care, and continuing data collection.

Answer 127

Implementation

Question 128

• It is primarily focused on working with the patient and the family to carry out the plan of care.

Answer 128

Implementation

Question 129

IMPLEMENTATION

PURPOSE:

Answer 129

To assist the pt in achieving valued health outcomes: promote health, prevent illness and disease restore health and facilitate coping with altered functioning

Question 130

UNIQUE FOCUS OF IMPLEMENTATION

Answer 130

In all nurse-pt interaction, the nurse is concerned with the pt response to health and illness and their ability to meet basic human needs

Question 131

IMPLEMENTATION

ACTIVITIES: (KOZIER)

Answer 131

• Reassess the client to update the database and review the plan of care (validating NCP)
• Determine need for nursing assistance
• Reformed planned nursing intervention
• Communicate what nursing actions were implemented
• Document care and client responses to care
• Give verbal reports as necessary (Taylor)
• Continue data collection, and modify the plan of care as needed

Question 132

VALIDATING CARE PLAN
GUIDELINES IN VALIDATING CARE PLAN:

Answer 132

• Does the plan assure the patient’s safety?
• Is the plan based on _ scientific principle?
• Is the plan supported by acceptable nursing knowledge
• Are the nsg dx. Supported by the data
• Are the major defining characteristics present?
• Priorities consider patient preference and physiological and psychological area
• Outcome _ to the problem identified in the nsg dx.
• Do the outcome _ & patient behavior for evaluation
• Can the planned nursing action realistically help the patient achieve

Question 133

4 Areas in Reviewing the Care Plan

Answer 133

Safety
Appropriateness
Effectiveness
Individualized Nursing Care

Question 134

IMPLEMENTATION SKILLS

Answer 134

Cognitive Skills (Intellectual Skills)
Interpersonal Skills
Technical Skills

Question 135

IMPLEMENTATION SKILLS

COGNITIVE SKILLS (INTERPERSONAL SKILLS)

Answer 135

• Problem solving
• Decision making
• Critical thinking
• Creativity

Question 136

IMPLEMENTATION SKILLS

INTERPERSONAL SKILLS

Answer 136

• All actions, verbal and nonverbal, people use when interacting directly with one another
• Effectiveness of a nursing action depends largely on the nurse’s ability to communicate with other
• Necessary in all act, caring, comforting, advocating, referring

Question 137

IMPLEMENTATION SKILLS

TECHNICAL SKILLS

Answer 137

• Are hand-on skills such as manipulating equipment

Question 138

PROCESS OF IMPLEMENTING

Answer 138

• Reassessing client
• Determining nurse need for assistance
• Implementing nurse intervention (primary component)
• Supervising delegated care
• Documenting nursing activities (if it was not done, it was not documented.)

Question 139

DELEGATING IMPLEMENTATION

DELEGATION:
ASSIGNMENT:

Answer 139

DELEGATION
• Transfer of responsibility from one person to another while retaining accountability for the outcomes
ASSIGNMENT
• Downward/_ transfer of both the responsibility and accountability of _ from one individual to another

Question 140

RESPONSIBILITY OF THE NURSE IN DELEGATION AND ASSIGNMENT

Answer 140

• Appropriate delegation of duties
• Adequate supervision or assigned in _

Question 141

GUIDELINES IN IMPORTANT NURSING INTERVENTIONS

Answer 141

• Base nursing intervention on scientific knowledge nursing research or professional
standard cae (evidence-based practice) whenever possible
• Clearly understand the orders to be
implemented and _ that are not understood
• Adapt actions to the individual client
• Implement safe care
• Provide _ support comfort
• Holistic
• Respect the dignity of the client and enhance self-esteem
• Encourage client in participating actions in implementing nursing intervention

Question 142

____ is composed of documenting responses to interventions, evaluating the effectivenes of interventions, evaluating outcome achievement, and reviewing the nursing care plan.

Answer 142

Evaluating

Question 143

EVALUATION

PURPOSE:

Answer 143

• Determine whether to continue, modify, or terminate the plant of care
• Allow patient achievement of expected outcomes in directed future nurse-patient interaction
• Based on the pt responses of the plan of care the nurse decide to _
1. Terminate the plan of care when expected outcome is achieved
2. Modify the plan of care if different _
3. _

Question 144

UNIQUE FOCUS OF NURSING EVALUATION

Answer 144

• Involved in many types of evaluation
• Measure patient outcome achievement
• Help targeted groups of patient achieve specific outcomes
• Competence of individual nurses
• Degree of external factors”
o Different types of healthcare services
o Specific equipment, procedure, socio-economic factors influenced health and wellness

Question 145

EVALUATION

ACTIVITIES: (KOZIER)

Answer 145

• Collaboration with client and collect the data related to desired outcomes
• Judge whether goals/outcomes have been achieved
• Relate nursing actions to client outcome
• Make decisions about problem status
• Review and modify plan of care

Question 146

EVALUATION

ACTIVITIES: (TAYLOR)

Answer 146

• Identify factors that contribute to the patient’s success/failure

Question 147

OUTCOME EVALUATION STATEMENT:

Answer 147

Outcome met
Outcome partially met
Outcome not met
+
Actual patient behavior as evidence

Question 148

OUTCOME EVALUATION STATEMENT

• Was able to demonstrate the
behavior by the specific time/date
in outcome statement

Answer 148

Outcome met

Question 149

OUTCOME EVALUATION STATEMENT

• Was able to but not as well

Answer 149

Partially met

Question 150

OUTCOME EVALUATION STATEMENT

• Was not able to

Answer 150

Not met