Nursing Process

Question 1

Diagnosing

Answer 1

The purpose of diagnosing is to identify the client’s health status. Accuracy is essential because the diagnosis is the basis for planning client-centered goals and interventions

Question 2

Health problem

Answer 2

is any condition that requires intervention to prevent or treat disease or illness. After you identify a health problem, you must decide how to treat it: independently or in collaboration with other health professionals. The answer determines whether it is a nursing diagnosis, a medical diagnosis, or a collaborative problem

Question 3

Nursing diagnosis

Answer 3

A statement of client health status that nurses can identify, prevent, or treat independently.
Stated in terms of human responses (reactions) to disease, injury, or other stressors.
A human response that can be biological, emotional, interpersonal, social, or spiritual, and can be either a problem or a strength.

Question 4

medical diagnosis

Answer 4

describes a disease, illness, or injury. Its purpose is to identify a pathology so that appropriate treatment can be given to cure the condition.

Question 5

differences between medical and nursing diagnoses:

Answer 5

A medical diagnosis is more narrowly focused than a nursing diagnosis.
You cannot predict a patient’s nursing diagnoses just by knowing his medical diagnosis or pathology

A medical diagnosis, disease, or pathological condition can have any number of nursing diagnoses associated with it.

Clients with the same medical diagnosis may have different nursing diagnoses.

Question 6

Collaborative problems

Answer 6

certain physiologic complications that nurses monitor to detect onset or changes in status
All patients who have a certain disease or medical treatment are at risk for developing the same complications

A collaborative problem is always a potential problem

If you can prevent the complication with independent nursing interventions alone, it is not a collaborative problem

Question 7

Diagnostic reasoning

Answer 7

is the thinking process that enables you to make sense of data gathered during a comprehensive patient assessment. It is also known as diagnostic process.

Question 8

To analyze and interpret data

Identify significant data

Answer 8

(1) Identify significant data, (2) cluster cues, and (3) identify data gaps and inconsistencies.

Significant data (also called cues):
Influence your conclusions about the client’s health status.
Usually are unhealthy responses.
Draw on your theoretical knowledge (e.g., of anatomy, physiology, psychology).
Are compared with standards and norms.
One cue should alert you to look for others that might be related to it (forming a pattern).

Question 9

Cluster cues

Answer 9

A cluster is a group of cues that are related to each other in some way. The cluster may suggest a health problem. KEY POINT: To help ensure accuracy, you should always derive a nursing diagnosis from data clusters rather than from a single cue.

Question 10

Identify Data Gaps and Inconsistencies

Answer 10

another example, look again at Todd’s (Meet Your Patient) data. Except for medical diagnoses, there are very few data. The following data gaps exist:

Look for inconsistencies in the data

Question 11

Draw Conclusions about health status

Answer 11

Step 1 . Make inferences

Nursing diagnoses are inferences—and are only your reasoned judgment about a patient’s health status. Try not to think of a diagnosis as being right or wrong but instead as being more accurate or less accurate. You can never construct a perfect diagnosis, but you must strive to make your diagnostic statements as accurate as possible to ensure that care is effective.
Step 2. Identify Problem Etiolgies

Question 12

Etiology

Answer 12

etiology consists of the factors that are causing or contributing to a problem

Etiologies may be pathophysiological, treatment related, situational, social, spiritual, maturational, or environmental. It is important to correctly identify the etiology because it directs the nursing interventions. Consider this nursing diagnosis:
Constipation related to inadequate intake of dietary fiber

An etiology is always an inference because you can never actually observe the “link” between etiology and problem.

Question 13

Verify problems with the patient

Answer 13

Think of nursing diagnoses as tentative, and be open to changing them based on new data or insights from the patient.

Question 14

Prioritize Problems

Answer 14

However, clients often have more than one problem, so you must use nursing judgment to decide which to address first and which are safe to address later. This is prioritizing.

Prioritizing puts the problems in order of importance, but it does not mean you must resolve one problem before attending to another.
You will usually prioritize problems as you are recording them.
You can indicate the priority by designating each problem as high, medium, or low priority or by ranking all the problems in order from lowest to highest (e.g., 1, 2, 3, 4).
Problem priority is largely determined by the theoretical framework that you use—for example, whether your criteria are human needs, problem urgency, future consequences, or patient preference.

Question 15

Computer-Assisted Diagnosing

Answer 15

Many institutions use computers for planning and documenting patient care. Some expert (knowledge-based) systems allow you to enter assessment data, and the computer program will then generate a list of possible problems.

Question 16

Bias

Answer 16

The tendency to slant your judgment based on personal opinion or unfounded beliefs, as the nurse did in the preceding example.

Question 17

Stereotypes

Answer 17

judgments and expectations about an individual based on the personal beliefs you have about a group when you have little or no actual experience with the group (e.g., men are unemotional; teenagers are irresponsible)

Question 18

Standardized language

Answer 18

one in which the terms are carefully defined and mean the same thing to all who use them.

Question 19

Standardized nursing languages

Answer 19

comparatively recent attempt to bring such clarity to communication about nursing knowledge, thinking, and practice. A standardized nursing language can do the following:

Support electronic health records.
Define, communicate, and expand nursing knowledge.
Increase visibility and awareness of nursing interventions.
Facilitate research to demonstrate the contribution of nurses to healthcare and influence health policy decisions (Shever, 2011).
Improve patient care by providing better communication between nurses and other healthcare providers and facilitating the testing of nursing interventions.

Question 20

Taxonomy

Answer 20

system for classifying ideas or objects based on characteristics they have in common.

Question 21

Collaborative problem

Answer 21

collaborative problem is always a potential problem (e.g., a complication of a disease, test, or medical treatment).

Question 22

Problem suggests goals

Answer 22

The goal, or outcome, is the opposite of the unhealthy response: Skin will remain intact and healthy.

The goals suggest assessments (a type of nursing intervention). For example, the diagnosis Risk for Impaired Skin Integrity tells you to monitor the patient’s skin conditio

If the problem is not an accurate statement of health status, then your goals and resulting assessments will be wrong

Question 23

Planning

Answer 23

Formal planning “is a conscious, deliberate activity involving decision making, critical thinking, and creativity” (Wilkinson, 2012). During the planning phases, you:
Work with the patient and family to derive desired outcomes from identified problems (e.g., nursing diagnoses).
Identify nursing interventions to help achieve those outcomes.

Informal planning occurs while you are performing other nursing process steps

Question 24

Initial and Ongoing Planning

Answer 24

Initial planning begins with the first patient contact. It refers to the development of the initial comprehensive care plan, which should be written as soon as possible after the initial assessment.

Ongoing planning refers to changes made in the plan (1) as you evaluate the patient’s responses to care or (2) as you obtain new data and make new nursing diagnoses

Question 25

Discharge planning

Answer 25

process of planning for self-care and continuity of care after the patient leaves a healthcare setting. The purpose of discharge planning is to (1) promote the patient’s progress toward health or disease management outside of facility care; and (2) reduce early readmissions to hospital care.

Question 26

comprehensive nursing care plan

Answer 26

The comprehensive nursing care plan (a type of patient care plan) is the central source of information needed to guide holistic, goal-oriented care to address each patient’s unique needs. It specifies dependent, interdependent, and independent nursing actions necessary for a specific patient.

Question 27

Standardized (model) nursing care plans

Answer 27

Standardized (model) nursing care plans detail the nursing care that is usually needed for a particular nursing diagnosis or for all nursing diagnoses that commonly occur with a medical condition. Figure 5-2 is a standardized care plan for a single nursing diagnosis. Although similar to unit standards of care, model care plans are different in that they usually:
Provide more detailed interventions than do unit standards of care.
Are organized by nursing diagnosis.
Include specific patient goals and nursing orders.
Become a part of the permanent record.
Describe ideal rather than minimum nursing care.
Allow you to incorporate addendum care plans.
Include checklists, blank lines, or empty spaces so that you can individualize goals and interventions.
KEY POINT: Model care plans can be used as guides, but they do not address a client’s individual, specific needs. For this reason, they may lead you to focus on the common, predictable problems and overlook an unusual—and perhaps more important—problem that the person is experiencing.

Question 28

Individualized Nursing Care Plans

Answer 28

Nurses use individualized care plans to address nursing diagnoses unique to a particular client. These care plans reflect the independent component of nursing practice and, therefore, best demonstrate the nurse’s critical thinking and clinical expertise.

Question 29

Computer Plans of Care

Answer 29

EHRs), including computer-generated care plans. The computer stores standardized plans (e.g., for nursing diagnoses, medical diagnoses, or diagnosis-related groups [DRGs]). When you enter a diagnosis or a desired outcome, the computer generates a list of suggested interventions from which to choose. You can individualize them by choosing from checklists or typing in your own interventions and strategies.

Question 30

rationales

Answer 30

Rationales state the scientific principles or research that supports nursing interventions. Writing rationales helps ensure that you understand the reasons for your interventions. For an example of a student care plan,

Question 31

Nursing interventions

Answer 31

Nursing interventions are actions based on clinical judgment and nursing knowledge that nurses perform to achieve client outcomes.

Direct-care interventions are performed through interaction with the client(s) (e.g., physical care, emotional support, and patient teaching).

Indirect-care interventions are performed away from the client but on behalf of a client or group of clients e.g., (advocacy, managing the environment, consulting with other members of the healthcare team, and making referrals).

Question 32

Independent interventions

Answer 32

s Nurse A makes a nursing diagnosis of Anxiety related to deficient knowledge about barium enema; she writes a nursing order to teach the patient what to expect from the upcoming diagnostic test.

independent intervention—one that registered nurses (RNs) are accountable for and are licensed to prescribe, perform, or delegate based on their knowledge and skills.
It does not require a provider’s order.
Knowing how, when, and why to perform an activity makes the action autonomous (independent).
Nurses prescribe and perform independent interventions in response to a nursing diagnosis. KEY POINT: As a nurse, you are accountable (answerable) for your decisions and actions with regard to nursing diagnoses and independent interventions.

Question 33

Dependent interventions

Answer 33

Nurse B reads a prescription in a patient’s chart: “Give cephalothin sodium (Keflin) 1 g IV [through the intravenous line] before surgery, and then every 6 hours for 24 hours.” She prepares and administers the medication.
This is a dependent intervention—one that is prescribed by a physician or advanced practice nurse but carried out by the nurse.
Dependent interventions are usually prescriptions for diagnostic tests, medications, treatments, IV therapy, diet, and activity.
In addition to carrying out medical prescriptions, you will be responsible for assessing the need for the prescription, explaining the activities to the patient, and evaluating the effectiveness of the prescription.
Example: After giving the Keflin (an antibiotic), Nurse B observes that the patient has developed a rash. Suspecting an allergic reaction, she contacts the prescriber so that the medication can be changed.

Question 34

Evidence-Based Practice

Answer 34

Evidence-based practice (EBP) is an approach that uses firm scientific data rather than anecdote, tradition, intuition, or folklore in making decisions about medical and nursing practice. In nursing, it includes blending clinical judgment and expertise, the best available research evidence, patient characteristics, and patient preferences. KEY POINT: The goal of evidence-based practice is to identify the most effective and cost-efficient treatments for a particular disease, condition, or problem. Steps in the EBP process include the following:

Question 35

Clinical practice guidelines

Answer 35

systematically developed statements to assist practitioners and patients in making decisions about appropriate healthcare for a particular disease or procedure

Question 36

The Clinical Care Classification (CCC),

Answer 36

), previously called the Home Healthcare Classification, was developed for use in home healthcare (Clinical Care Classification (CCC) System, 2012; Saba, 1995). In addition to terminology for nursing diagnoses and outcomes, the CCC (Version 2.5) has more than 800 nursing interventions. For a complete description of the CCC system, see the nursing process section of Chapter 42 and

Question 37

Omaha System

Answer 37

developed for community health nurses to use in caring for individuals, families, and aggregates (community groups or entire communities) (Martin, 2005). In its present form, it is designed to communicate multidisciplinary practice for a broad spectrum of patients and levels of health. It includes terminology for diagnoses, outcomes, and interventions. For a complete description of the Omaha System, see the nursing process section of Chapter 42 and

Question 38

Nursing Orders

Answer 38

instructions that describe how and when nursing interventions are to be implemented. They are usually written on a nursing care plan. Other nurses and nursing assistive personnel (NAP) are responsible and accountable for implementing nursing orders.

Question 39

How is implementation related to other steps of the nursing process??

Answer 39

Implementation overlaps with assessment. Nurses use assessment data to individualize interventions Implementation provides the opportunity to assess your patient at every contact. When performing an ongoing assessment, you are both implementing and assessing.
Example: In Meet Your Patients, what data did the nurse obtain while bathing Mrs. Wu? What ongoing assessment was ordered for Mrs. Wu?
Implementation overlaps with diagnosis. Nurses use data discovered during implementation to identify new diagnoses or to revise existing ones.
Example: What new nursing diagnosis did the nurse make for Mrs. Wu after bathing her?

Question 40

Implementation

Answer 40

Doing
Delegating
Recording

Question 41

Preparing for Implementation

Answer 41

Check your knowledge and abilities

Clarify orders. As a nurse, you are obligated ethically and legally to clarify or question orders that you believe to be unclear, incorrect, or inappropriate.
Be sure you are qualified/authorized. Is the action allowed by your state’s nurse practice act, your facility’s policies and procedures, and your job description? Is it allowed by your instructor or supervisor? Do you have the required knowledge, skill, and experience? Can you accept accountability for the outcomes of your action?
Be sure the action is safe, reasonable, and prudent. Assess the patient to see whether the action is still indicated. Have you checked for contraindications, identified possible harmful patient responses, and minimized risks? Do you have a plan for what to do if something does not go as planned? Have you planned for safety, privacy, and comfort? Have you considered whether the action is ethical (Alfaro-LeFevre, 2007)?

Question 42

feedback

Answer 42

This means that you observe how the patient is responding to the activity as you perform care. Because this evaluation is done before the intervention is complete, we call it feedback. Feedback is not always verbal; it could be a change in vital signs, skin color, or level of consciousness, as in the example above.

Question 43

How can I promote client participation and adherence?

Answer 43

Many interventions depend almost entirely on the patient’s adhering to the therapy

People fail to follow therapeutic regimens for various reasons,

People need access to information that they can understand,

People need access to information that they can understand,

Question 44

Collaboration

Answer 44

simply means working with patients and other caregivers (e.g., physicians, therapists, nutritionists) to plan, make decisions, or perform interventions.

Question 45

Coordination

Answer 45

Coordinating care includes scheduling treatments and activities with other departments (e.g., laboratory, physical therapy, radiology). But it is more than that. Nurses are the professionals who have the most frequent and continuous contact with the patient, so they have the most complete picture of the person.

Question 46

5 rights of delegation

Answer 46

Right Circumstance
Right Task
Right Person
Right direction/communication
Right supervision/evaluation

Question 47

Evaluation

Answer 47

final step of the nursing process, is a planned, ongoing, systematic activity in which you will make judgments about:
The client’s progress toward desired health outcomes.
The effectiveness of the nursing care plan.
The quality of nursing care in the healthcare setting.

Evaluation and the assessment step both involve data collection. The difference is in when you collect and how you use the data.

Question 48

Why is evaluation essential to full-spectrum nursing?

Answer 48

he patient is the nurse’s first priority

Evaluation helps nurses to conserve scarce resources.

Professional standards of practice require evaluation

The ANA Code of Ethics requires evaluation

The Joint Commission and other professional standards review organizations require evaluation.

Evaluation helps ensure nursing’s survival

Question 49

How are standards and criteria used in evaluation?

Answer 49

For formal evaluation, however, you must decide in advance which standards and criteria you will use. In nursing, standards are used to describe quality nursing care.

Criteria and competencies

Patient goals and outcomes

The ANA’s standards of practice

Question 50

Reliability

Answer 50

criterion is reliable if it yields the same results every time, regardless of who uses it.

Question 51

Validity

Answer 51

criterion is valid if it is really measuring what it was intended to measure.

Question 52

Types of Evaluation?

Answer 52

Structure Evaluation-focuses on the setting
Process Evaluation-manner at which care is given—the activities performed.
Outcomes Evaluation-focuses on observable or measurable changes in the patient’s health status that result from the care given

Question 53

Ongoing, Intermittent, and Terminal Evaluation

Answer 53

Ongoing- performed while implementing care immediately after an intervention
Intermittent evaluation-performed at specific times
Terminal evaluation-describes the client’s health status and progress toward goals at the time of discharge

Question 54

Quality Assurance Programs

Answer 54

These are specially designed programs to promote excellence in nursing. Variations of quality assurance are quality improvement, continuous quality improvement, total quality management, and persistent quality improvement.

Question 55

Documentation

Answer 55

Documentation is the act of recording patient status and care. KEY POINT: Documentation can be in written or electronic form or in a combination of the two forms. Documentation is the act of making a written record. The terms documenting, recording, and charting are often used to mean the same thing. Oral communication about a patient’s status is called reporting—that is discussed later in this chapter.